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Gender Dysphoria: Bioethical Aspects of Medical Treatment

Marta r. bizic.

1 Belgrade Center for Genital Reconstructive Surgery, Serbia

2 University Children's Hospital, Belgrade, Serbia

Milos Jeftovic

3 School of Medicine, University of Belgrade, Serbia

Slavica Pusica

Borko stojanovic, dragana duisin, svetlana vujovic, vojin rakic.

4 Center for the Study of Bioethics, University of Belgrade, Serbia

Miroslav L. Djordjevic

Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.

1. Introduction

Gender dysphoria (GD) represents a condition where a person's gender assigned at birth and the gender with which they identify themselves are incongruent. Hence, these individuals can be very uncomfortable with their biological sex, primary and secondary sex characteristics, and social gender roles and they experience various levels of distress. Presence of public figures who are openly transgender, their appearance in mainstream media, and political and social climate lead to more individuals coming out in the open as to their state. Prevalence rate cannot be correctly estimated considering that people are still hesitant to come forward to health centers. According to DSM-5, the prevalence of gender dysphoria is 0.005-0.014% for adult natal males and 0.002-0.003% for adult natal females [ 1 ].

In accordance with their wishes, individuals with this condition can choose the direction in which their transition will proceed. To take the edge off their state, one can choose to go through a social transition. The social transition includes using a different name, pronouns, transformation of physical appearance, use of suitable bathrooms, and taking social roles of the affirmed gender. A more radical approach is the medical transition that includes hormonal and surgical treatment. Medical treatment requires a team of experienced experts, and it usually includes mental health professionals, endocrinologists, and surgeons. Psychiatric assessment is the first step and is very complex because it is necessary to exclude other conditions that might mimic gender dysphoria. The next step is hormonal treatment, under the care of an endocrinologist, which is then followed by “a real-life trial.” Some individuals decide to stop here, while others continue to gender-affirming surgery (GAS). The seventh edition of the Standards of Care of the World Professional Association of Transgender Health (WPATH) offers flexible guidelines for the treatment of people experiencing gender dysphoria and describes the criteria for surgical treatment [ 2 ]. Patients undergoing GAS of their choice are required to provide two recommendation letters from certified psychiatrists and a gender specialist, as well as a confirmation of having been on hormonal therapy prescribed by an endocrinologist for a period of a minimum of one year. Gender affirmation surgery refers to all surgical procedures that a patient wishes to undergo in an attempt to become as similar as possible to the desired gender.

Treatment of gender dysphoria always raised numerous ethical issues, and with rapid acknowledgment and recent achievements, new complex issues in medical management have emerged. With unknown etiology and questionable definition (mental/medical illness, social construct, and variation of sex) who can decide, with 100% certainty, what treatment is in the best interest of a particular patient? The most prominent challenges and ethical questions pertain to the treatment of underage individuals, fertility after GAS, and possibility of regret after GAS. Main ethical principles are autonomy, beneficence, nonmaleficence, and informed consent. The individual must have autonomy of thought and intention when making decisions about medical treatment. This is an especially sensitive field in treatment of gender dysphoria, because sometimes the individual's desires, hopes, and expectations might not correlate with reality. Experts must be very straightforward regarding specific possibilities, risks, and benefits of medical treatment, especially considering that the last step in medical transition, GAS, is irreversible. Beneficence implies doing only good, only what is in the patient's best interest. However, some may consider that surgical alteration of healthy organs, in case of GAS, is not in line with this principle. Nonmaleficence must ensure that the treatment does not harm the individual in an emotional, social, or physical sense. Always keeping these principles in mind, WPATH Standards of Care and criteria for diagnosis might not be enough to be ascertain that we are doing the right thing. Although it may seem that an individual fulfills all these criteria on paper, sometimes we can observe their personal disadvantages, youth, impairment, or desperation. It seems that, even with the reassurance and recommendation from a mental health professional, ethical unease cannot be entirely erased because treatment guidelines have preceded the answers to vitally relevant questions [ 3 , 4 ].

2. Transgender Youth

Children represent a small number of individuals with gender dysphoria and in only 10-20% of the children, gender dysphoria will continue to manifest in adolescence [ 5 ]. However, psychological therapy and support are highly recommended; while such services are now far more widely available, they are still insufficient to provide for complete wellbeing of these patients. Inadequate management of children with persistent gender dysphoria can lead to isolation, feeling of self-hatred, and suicidal ideas and attempts. Also, “passing through the wrong puberty” can have serious consequences for these individuals. Viable treatment options vary from fully reversible treatment, such as puberty-suppressing gonadotropin-releasing hormone analogues (GnRH) to partly reversible treatment, gonadal steroid treatment, as well as irreversible treatment, such as surgical removal of genitalia and reconstruction of new ones according to the desired gender. Surgery includes bilateral mastectomy with chest reconstruction, hysterectomy with oophorectomy followed by either metoidioplasty or phalloplasty for trans-male individuals, and bilateral orchiectomy with penectomy followed by vulvoplasty and vaginoplasty in trans-female individuals [ 6 ].

Pubertal suppression is implemented using GnRH analogues at Tanner 2 or 3 stage of puberty. Hypothalamus produces GnRH at low levels in prepubertal children. Levels become cyclical during puberty, leading to the production of luteinizing hormone (LH) and follicle stimulating hormone (FSH) by the anterior pituitary. LH and FSH stimulate ovaries and testicles to produce sex hormones, estrogen and testosterone, which are responsible for stimulating the growth of genitalia. Also, they lead to the development of breasts, voice deepening, menstrual cycle, and so forth, which transgender youth can find particularly tough to handle [ 7 ].

There are only a few reports related to the use of GnRH analogues in transgender youth. De Vries et al. were the first to introduce the concept and research on the use of puberty blockers for treatment of transgender youth. The main idea behind the suppression of endogenous puberty was to decrease distress by preventing the development of “noncongruent” secondary sexual characteristics. This would give young individuals more time to get accustomed to their situation and to better explore their gender. In the examined group, all of 70 eligible candidates showed improved mental health and general functioning. Authors concluded that the treatment was fully reversible, which was one of its main advantages [ 8 ]. Despite the positive outcomes in puberty suppression, many experts still have concerns and resist the implementation of this treatment in their regular practice. Viner et al. proposed that GnRH therapy can be physically damaging for teenagers and can lead to unfavorable psychological consequences [ 9 ]. Olson-Kennedy et al. also recognized these dilemmas, stating that available data on puberty suppression was limited and many questions remained unanswered [ 10 ]. One of the main reasons against this treatment is that going through puberty may help the individual to become congruent with their biological sex, meaning that their GD would not persist into adolescence. Results from Steensma et al. showed that majority of children developed homosexual orientation after completion of the GnRH treatment [ 11 ]. As for potential consequences, Hembree recently reported no long-term consequences in follow-up studies of GnRH treatment [ 12 ].

Finally, the decision about implementing GnRH treatment is very difficult and cannot be made without ethical dilemmas. Both opponents and advocates of pubertal suppression are guided by the same ethical principles, beneficence, nonmaleficence, and autonomy, but have different views on where these principles lead. A unique and clear overview is necessary, and, to this day, it has not yet been elaborated. Considering that GnRH treatment is relatively new and controversial, additional qualitative research and empirical studies are necessary for appropriate bioethical definitions.

Transgender persons require safe and effective hormonal support to develop the physical characteristics that affirm their gender identity. The main indications for the beginning of hormonal therapy are confirmed persistence of gender dysphoria and adequate mental capacity to give informed consent and accept this partially irreversible treatment. According to the most recent Endocrine Society guidelines, most adolescents develop this capacity by the age of 16 [ 12 ]. Also, Hembree et al. recognized some compelling reasons to initiate sex hormonal therapy before 16, but there is little data published on the experiences with this treatment prior to 14 years of age [ 12 ]. The main goals of cross-sex hormonal therapy are suppression of endogenous sex hormone secretion, determined by the person's genetic/gonadal sex, and maintaining sex hormone levels within the normal range for the person's affirmed gender. This therapy harmonizes the external appearance with affirmed gender, leading to, in transgender men, male-sounding voice, different fat distribution, increase in muscle mass and, in transgender women, breast growth, decreased facial and body hair, more feminine fat redistribution, and decreased muscle mass [ 12 ].

Many studies demonstrated long-term safety and high efficiency of hormonal therapy in transgender adults. For trans-women, Asscheman et al. emphasized a warning to a side effect of particular concern, estrogen-induced hypercoagulability and subsequent venous thromboembolism. Hembree addressed some potential adverse physical effects of testosterone treatment, such as polycythemia vera and dyslipidemia, in transgender men. Generally, a majority of the authors concluded that this therapy was safe, with necessary follow-up for potential complications [ 12 – 14 ]. However, only a few studies looked into the impact of cross-sex hormonal therapy on transgender youth. Jarin et al. performed a retrospective study on 116 adolescents aged 14–25 years with gender dysphoria and have reported minimal impact of hormone treatment. In trans-men, the only findings were an increase in hemoglobin, hematocrit, and body mass index with lowering of high-density lipoprotein levels; in trans-women, only lower testosterone and alanine aminotransferase (ALT) were reported [ 15 ]. Olson-Kennedy et al., in their prospective study, found several statistically significant changes in mean values of physiological parameters over time but of no consequence to clinical safety concerns [ 16 ]. In both studies, the authors indicated that this cross-sex hormonal therapy is safe for transgender youth over a period of approximately two years. However, the strongest argument against cross-sex therapy lies in the lack of knowledge of its long-term effects, which means that more studies and follow-up information are necessary. One of the questions is a possibility for cross-sex hormonal therapy in individuals below 16 years of age. The authors of the latest guidelines of the Endocrine Society recognized this possibility but only on a “case by case” principle, meaning that age does not always accurately reflect one's readiness for medical interventions. Also, some experts noticed that a clear majority of children on GnRH therapy will decide to pursue cross-sex hormonal therapy. Only a few side effects of using GnRH were observed, such as decreased bone density [ 17 ].

Based on bioethical principles, children usually do not have the power to make legal decisions and actions at the initiation of cross-hormonal therapy. Nevertheless, their judgment and opinions should not be disregarded. Cross-sex therapy primarily helps individuals with GD to harmonize their external appearance with their experienced gender. In this case, proper education of the patient and pointing out advantages and shortcomings of such treatment are of crucial importance. Following the principle of beneficence, clinicians are always obliged to help the person and to follow the prescribed hormonal treatment, since there are no better options at this moment. Patients who are denied treatment can develop serious psychological consequences. Generally, the transgender population is at higher risk of self-harm and suicide [ 18 ]. A more individualized approach, as in the “case by case” system, will ensure that a right decision is made in accordance with the patient's maturity, age, and judgment.

Gender affirmation surgery is the last step in the medical transition. It is considered to be irreversible and is technically demanding to perform, even for experienced surgeons. According to WPATH Standards of Care, a criterion for eligibility for GAS is “reached legal age of maturity in a given country.” Presumably, the threshold is 18 years of age in most countries [ 19 ]. The increasing usage of puberty blockers and pushing the limits for the start of the cross-sex hormone therapy lead to further problems and dilemmas. With these developments, it was only a matter of time before the issue of GAS in minors would arise. Viewpoints are different and vary between the beneficence principle embodied in the motto “doing nothing is doing harm” and the nonmaleficence variation of “the treatment plan that involves less extensive surgery or none at all,” reported by Cohen-Kettenis and Holman, respectively [ 20 , 21 ].

Changing the legislation for hormonal therapy without GAS increases the gap between the two medical procedures and postpones the desired outcome of the transition. During this interim period, someone living with atypical genitalia can easily be exposed in public and lose control over something that used to be very private [ 22 ]. Transgender community is more often targeted by bullying and has higher rates of suicide. Leaving these patients to wait for the final stage in their transition can have an impact on their social and psychological state. Goffman's theory of stigma postulates that the transitioning adolescents must prove their affirmed gender to others [ 23 ]. If others question the individual's gender identity, including the presence of gender-congruent genitals, he or she fails to manage the stigma and becomes “discredited.” In addition, postponing romantic relationships and dating until the age of 18 can also lead to psychological struggles and challenges.

On the other hand, the main “technical” issue in case of children treated with puberty blockers lies in their undeveloped genitalia. Thus, the GAS will be more troublesome, especially in case of penile inversion vaginoplasty. Some authors reported autologous skin grafting from donor site or use of bowel segments as viable solutions for this issue [ 24 , 25 ]. However, the main concern is the possibility of regret after the GAS. As already mentioned in Introduction, GD does not persist through adolescence in the vast majority of children. The results of GAS in transgender minors and their possible regret are a great cause of concern and a huge responsibility for medical professionals [ 26 ]. The dilemmas remain: is it better to suffer the consequences of GD or GAS? Are children or teenagers mature enough to make these kinds of decisions? Further research and data are necessary to resolve these crucial dilemmas.

3. Fertility

Treatment of GD enables the individuals to continue their life in their affirmed gender. For some transgender individuals, this implies the same as for cisgender persons, marriage or/and children. Members of the transgender population have the same desire for offspring, for the same reasons as the cisgender population, and fertility presents one of the most delicate issues. Infertility in trans-women is caused by orchiectomy as a part of the GAS. Conversely, hysterectomy and oophorectomy eliminate the chance of pregnancy in trans-men. Cross-sex hormonal therapy also has an impact on fertility, but such treatment is not a definitive cause of infertility, due to the possibility of reversal. Three decades ago, Payer described that estrogen in trans-women leads to the reduction of testicular volume and has a strong suppressive effect on sperm motility and density [ 27 ]. Testosterone therapy for trans-men leads to reversible amenorrhea according to Van Den Broecke's study in 2001 [ 28 ]. Patients are usually at full reproductive age at the initiation of their transition and a clear majority of them express the desire for reproductive potential after transition [ 29 , 30 ]. This is almost impossible, as irreversible transition means losing the option for having children. Dunne reviewed sterilization requirements for transgender people in Europe and found sterilization as the only possible option in 20 European countries; this means that any chance for biological offspring is lost with this transition [ 31 ]. This discrimination deeply undermines the fundamental bioethics law, and societies such as WPATH and the Endocrine Society advocate for counseling and detailed explanation of the consequences of treatment and viable options for fertility preservation. In addition, the possibility of sterility following the use of puberty blockers and cross-sex hormones gives rise to further controversy and ethical dilemmas, as do options of cryopreservation prior to the start of cross-sex hormonal therapy and uterus transplantation for trans-women.

As we have previously mentioned, puberty blockers are considered to be the reversible part of the transition, preventing secondary sex characteristics from developing. However, some authors confirmed that these blockers also have an impact on maturation of germ cells, which could be used for preservation of the biological fertility potential [ 32 ]. Individuals on puberty suppression therapy may show an interest in offspring but, at the same time, may not want to pass through the wrong puberty in the gender assigned at birth. Thus, their options for offspring are very limited, since prepubertal cryopreservation is still in the experimental stages [ 33 ]. There are other questions as well, including their maturity for making these kinds of decisions and the responsibility of their parents as legal guardians. In the literature, a few authors reported the desire of transgender people to have children and found that about half of both trans-men and trans-women wanted offspring after transition [ 29 , 34 ].

Cryopreservation of embryos, oocytes, or ovarian tissue is a viable option for trans-men. Some authors recommend cryopreservation just before initiation of hormonal transition due to the possibility that cross-sex hormone therapy might cause amenorrhea or affect follicle growth. In cases where the hormonal transition has already started, they suggest an interruption of hormone treatment for minimum 3 months with a goal to revert any potential therapy-induced effects [ 35 ]. These could be very aggravating facts, since other doctors reported that majority of transgender individuals did not want to postpone their transition for these procedures. Interestingly, Wallace et al. noticed that transvaginal ultrasound examination, as a necessary part for cryopreservation of embryos and oocytes, is not always in accordance with individuals' male identity and can lead to distress [ 36 ].

Sperm cryopreservation, surgical sperm extraction, and testicular tissue cryopreservation could be offered as possibilities for preserving fertility in trans-women. The issues with hormonal therapy exist in this case, too. De Sutter et al. described additional distress, caused by masturbating in clinical settings or sperm banking as a reminder of their former gender [ 34 ].

In some countries, cryopreservation is not technically available to the transgender population and thus cannot be offered during the transition. Despite the fact that cryopreservation is a routine procedure in case of malignant diseases, it still remains a controversial topic in less economically developed countries.

In some countries, like USA, sterilization is not mandatory and trans-men can keep their ovaries and uterus for later pregnancy. They must discontinue cross-sex therapy in this period. Light et al. described transgender pregnancies and challenges that come with this phenomenon [ 37 ]. Conversely, pregnancy is still not an option for trans-women. There is hope on the horizon from the first successful uterus transplantation, performed by a gynecology team from Sweden [ 38 ]. This is a solution for all women suffering from absolute uterine infertility who want to carry their own children. This procedure brings a new insight for researchers, making the possibility for transplantation in trans-women realistic. The main problems could arise from the different anatomy of the male pelvis, as well as from immunosuppressive therapy.

Fertility, including all the related issues and dilemmas, should be discussed very profoundly and meticulously. Transgender population should be informed about all possibilities, advantages, and drawbacks before any treatment and each option should ultimately be the patient's decision.

4. Regret and Revision Surgery

There are various levels of regret after GAS. Definite regret happens when the patient wants to get back to their gender assigned at birth after the GAS is performed. They come to surgeons with the request for the restitution of congenital anatomical features. Regret manifests with a more or less pronounced expression of dissatisfaction and second thoughts about the GAS. After suicide, regret could be considered one of the worst possible complications.

Reasons for regret vary greatly. Inadequate social adaptation, comorbidity with certain psychiatric disorders, poor psychological and psychiatric evaluation, and dissatisfaction with aesthetic or functional outcome of GAS can lead to regret. Researchers have concluded that the presence of the following factors can be associated with a risk of regret: age above 30 years at first surgery, personality disorders, social instability, dissatisfaction with surgical results, and poor support from partner or family [ 39 – 41 ].

In 2016, we published a retrospective analysis of seven patients who underwent reversal surgery after regretting undergoing male-to-female GAS elsewhere [ 42 ]. Main reasons for regret in these cases were related to inadequate psychiatric assessment. First stages of transition like the “real-life experience” were mostly skipped, cross-sex hormonal therapy was not carried out properly, and letters of recommendation were written by psychiatrists who lacked experience. Also, main diagnostic criteria for gender dysphoria had been neglected. It is therefore important to avoid situations where inadequately trained or inexperienced psychologists or psychiatrists work with transgender patients without supervision or collaboration with more experienced colleagues. Satisfying postoperative results were achieved in all patients. Reversal surgery significantly enhanced their general well-being.

Each regret occurrence represents a major issue for every expert in the field of transgender medicine. Proper diagnosis and listening to and monitoring our patients are of crucial importance for avoiding these kinds of mistakes [ 43 ]. Every physician should be aware that not all individuals suffering from GD want or need all three elements of therapy.

5. Conclusion

All physicians included in gender dysphoria treatment are facing great bioethical challenges and dilemmas. A multidisciplinary approach is necessary, but it does not always guarantee a successful outcome. The most sensitive issues are the treatment of transgender youth, fertility and parenting in transgender individuals, and the risk of regret after the irreversible part of the treatment, the gender affirmation surgery. In order to avoid the complex issue of regret, proper preoperative evaluation by experienced professionals, psychologists, and psychiatrists is necessary. More research and studies are necessary to shed light on these issues.

Acknowledgments

This work is supported by Ministry of Science and Technical Development, Republic of Serbia (Project no. 175048).

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.

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Starting Point: the World Professional Association of Transgender Health Standards of Care

Initial ethics discussions, is there a sound medical rationale for the treatment or surgery to be provided through the center is such treatment or surgery consistent with the practice of evidence-based medicine, is establishment of the center consistent with the hospital’s mission, does the establishment of the center, and the delivery of its services, demonstrate respect for human dignity and worth, does the establishment of the center, and delivery of its services, demonstrate respect for patient autonomy, if the procedures performed by the center elicit some public criticism on the basis of religious or moral views, how should the hospital respond, how will the center show respect for, and accommodate, religious or moral objections by staff to participating in the procedures offered by the center, how should the center allocate resources in the event that the need for services exceeds capacity, the dilemma of patient age, conclusions, acknowledgments, ethical issues considered when establishing a pediatrics gender surgery center.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Elizabeth R. Boskey , Judith A. Johnson , Charlotte Harrison , Jonathan M. Marron , Leah Abecassis , Allison Scobie-Carroll , Julian Willard , David A. Diamond , Amir H. Taghinia , Oren Ganor; Ethical Issues Considered When Establishing a Pediatrics Gender Surgery Center. Pediatrics June 2019; 143 (6): e20183053. 10.1542/peds.2018-3053

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As part of establishing a gender surgery center at a pediatric academic hospital, we undertook a process of identifying key ethical, legal, and contextual issues through collaboration among clinical providers, review by hospital leadership, discussions with key staff and hospital support services, consultation with the hospital’s ethics committee, outreach to other institutions providing transgender health care, and meetings with hospital legal counsel. This process allowed the center to identify key issues, formulate approaches to resolving those issues, and develop policies and procedures addressing stakeholder concerns. Key issues identified during the process included the appropriateness of providing gender-affirming surgeries to adolescents and adults, given the hospital’s mission and emphasis on pediatric services; the need for education on the clinical basis for offered procedures; methods for obtaining adequate informed consent and assent; the lower and upper acceptable age limits for various procedures; the role of psychological assessments in determining surgical eligibility; the need for coordinated, multidisciplinary patient care; and the importance of addressing historical access inequities affecting transgender patients. The process also facilitated the development of policies addressing the identified issues, articulation of a guiding mission statement, institution of ongoing educational opportunities for hospital staff, beginning outreach to the community, and guidance as to future avenues of research and policy development. Given the sensitive nature of the center’s services and the significant clinical, ethical, and legal issues involved, we recommend such a process when a establishing a program for gender surgery in a pediatric institution.

As part of the development of the Center for Gender Surgery at Boston Children’s Hospital (BCH), the surgical team decided to initiate a process of ethical and legal consultation. As the first gender surgical center to be housed in a pediatric facility in the United States, it was expected that there would be ethical and legal concerns that were unique to the setting, in addition to the broader concerns around gender surgery raised by other authors. 1 , 2 In the fall of 2017, these concerns were raised over a series of discussions with the hospital’s administration, ethics committee, legal team, community members, and other stakeholders, and several concerns were identified that might be relevant to both this center and other centers working with younger transgender patients.

The World Professional Association of Transgender Health (WPATH) has laid out standards of care (SOC) 3 for the treatment of gender-nonconforming people. Although these SOC are in the process of being reviewed and revised, 4 and are not without controversy, 2 , 5 , – 8 the center team decided to use them as a starting point for policy development. As a starting point, the center decided to follow recommendations in the SOC that state that patients are not eligible for genital surgery until they have reached the age of majority and have lived for at least a year in their affirmed gender. Twelve months of hormone therapy is also required, unless hormone therapy is not clinically indicated. 3 With respect to chest surgeries, the SOC state that “Chest surgery in [female-to-male] patients could be conducted earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. 3 ” Other requirements for chest surgery in both men and women are persistent, well-documented gender dysphoria; capacity to make an informed decision; and evidence that any significant medical and mental health conditions are well controlled. (Note, the requirements for living in the affirmed gender do not require living in a binary gender.) Another important aspect of the SOC guidelines is the requirement for screening by a behavioral health professional, which is designed to provide the surgeon with relevant information about the patient’s gender identity and overall mental health. That screening is provided to the surgeon in the form of a letter, required for most insurance authorizations, that establishes the patient's suitability for gender affirming surgery. This requirement is somewhat controversial and has occasionally been referred to as “gatekeeping.”

Despite their awareness of this controversy, the center staff believed it was appropriate for the care paradigm to include a surgery-specific behavioral health assessment. The implemented protocol covers general readiness for surgery, case management issues that may occur around the time of surgery, assessment of whether the patient’s expectations for surgery are realistic, awareness of postsurgical care requirements and likelihood of compliance, gender history, and fertility assessment.

The center staff consists of a multidisciplinary team of surgeons (2 plastic surgeons, 1 urologist), midlevel providers, nurses, a social worker and researcher, an administrator, and a designated research specialist. The idea for the center originated with the 3 surgeons, who serve as codirectors. After a year of planning and seeking out professional development options in transgender care, the codirectors brought the social worker and researcher onto the team because of her extensive experience working with the gender-diverse patient population. Together, those 4 team members drafted an evidence-based proposal for how the center would be structured and how care would be delivered. They also prepared a presentation in which they highlighted the needs of young people for gender-affirming surgery, key criteria and conceptual underpinnings for offering the surgery (including the SOC), and specific surgical solutions. This material was then presented to the hospital ethics committee for discussion. The ethics committee includes members from a range of medical and surgical services, nursing, patient care services, social services, pastoral care, and other clinical services as well as community representatives and ex-officio participants from administration and legal counsel. 9  

The ethics committee meeting lasted ∼2 hours, and there was a vigorous discussion of concerns across a broad range of domains. A smaller team of ethics committee members and ethics staff then distilled the discussion points into an outline of ethical issues and general recommendations for approaches the center might follow in determining how to address them. This document was brought back to center staff and used to inform policy development and help formulate the center’s mission and values statements ( Fig 1 ). As additional issues, particularly those around the intersection of hospital policy, state law, and fertility preservation, arose for center staff, less-formal discussions were held with ethics and/or legal teams to explore relevant factors to be considered by the center in developing its policies.

FIGURE 1. Mission statement and values.

Mission statement and values.

Key questions that arose from the ethics discussions are addressed below.

Gender dysphoria is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the distress that occurs when there is a marked incongruence between the gender a person was assigned at birth and the gender that they experience or express. 10 The experience of gender dysphoria, and/or identifying as transgender, has been associated with a number of serious physical and mental health disparities, including elevated risks of depression, anxiety, suicidality, substance abuse, and HIV. 11 , – 15 Some of these disparities can be reduced with access to transgender-affirming health care and gender affirmation procedures. 11 , 16  

The center planned to offer gender affirmation chest reconstruction, phalloplasty, and metoidioplasty for transmasculine individuals (those assigned female at birth with a more male gender identity) and breast augmentation and vaginoplasty for transfeminine individuals (those assigned male at birth with a more female gender identity). Although the quality of the evidence base is low and relies mostly on short-term follow-up, the limited existing reports suggest that these treatments can be an effective way to improve gender congruence and body satisfaction for transgender individuals who are interested in such surgeries, and they have also been shown to improve depression, anxiety, and overall quality of life. 17 , – 24 Reports of regret do occur, but they are rare, affecting <1% of patients in 1 large study. 25 This rate is substantially lower than for breast reconstruction after mastectomy, a contextually similar surgical procedure (reconstructive but optional, often involving body image and sexuality) for which decision regret has been studied. 26 , 27 On the basis of research in the field, the clinicians were able to present solid evidence that the treatments to be provided at the center were medically sound and necessary to improve the health and well-being of the patients to whom they would be provided, including reduction or alleviation of symptoms of gender dysphoria.

Genital affirmation surgeries, such as vaginoplasty and phalloplasty, are generally offered to adult patients rather than pediatric patients. Therefore, one of the questions that received substantial discussion at the ethics meeting was whether and how these surgeries fit into the mission of a pediatric hospital, including its primary commitment to the health and well-being of pediatric patients. The hospital’s patient care policy defines pediatric patients as those who are under the age of 21.

The conclusion that the program was consistent with the hospital’s mission was based on several factors. First, the hospital’s mission statement addresses the importance of serving unmet need. Because of this mission, the hospital had previously established that it is appropriate to follow pediatric conditions into adulthood when other specialty care for these conditions is not available. In fact, a number of hospital departments, including surgical specialties, already provided care for patients into or through adulthood, and the hospital also had standard criteria for patients being treated through age 35. Because gender dysphoria is often a condition that originates in childhood, it meets the basis of that criteria to the extent that equivalent care is not available. 28 , 29 Evidence was presented that there was currently a significant unmet need for gender affirmation procedures in New England. Although several surgeons offered chest surgeries in the Boston area, there was limited access to care for adolescents. There was one other surgical team in the area offering genital affirmation surgeries for transgender women, but genital affirmation surgeries for transgender men were completely unavailable in the area before the opening of the center. As such, one of the motivations for forming the center was the community reaching out to local hospitals looking for providers to address this gap in care. While it might, on the surface, make more sense to offer genital surgeries for transgender men at an adult hospital, at the time the center was formed, there were no surgeons in local adult facilities interested in providing that care. In contrast, the center surgeons had both appropriate expertise and interest in addressing the unmet need.

In addition to the unmet need in the area as a whole, clinical leaders at BCH also recognized an unmet need affecting current patients and appealed to the hospital for support. The hospital houses the Gender Management Service 30 , 31 (GeMS), a leader in medical gender affirmation for transgender youth that was founded in 2007 and currently works with hundreds of patients a year. However, when GeMS patients were ready to surgically transition, their care had to be referred outside of the hospital system. There was agreement by center staff and hospital leaders that a dedicated gender surgery center would best serve the hospital’s mission by providing comprehensive care options and continuity of care for those transgender adolescents and young adults who had been treated in GeMS and were interested in surgical affirmation. Although the 2 programs run entirely separately, the location of the center in a pediatric hospital, with access to the expertise of GeMS providers, meant that it was also well placed to address the particular psychological and medical challenges experienced by transgender youth, including an elevated risk of bullying, violence, and other forms of school-based harrassment. 32 , – 34  

The hospital’s mission also includes research and education. Given its academic nature, and the presence of the GeMS program, the center is well situated to contribute to research in the field of transgender care (especially continuity of care from prepuberty to adult transitioning). The center can also support the hospital’s commitment to education, as is more fully described below.

Respect for human dignity and worth, including support for individual self-determination, are fundamental elements of medical ethics. 35 The hospital has a stated commitment to serving a diverse population, representing many nationalities, cultures, faiths, and value systems as well as those with diverse gender identities and sexual preferences. The ethics discussion process addressed this question by examining research in which it was shown that identifying with a gender that is inconsistent with one’s physical characteristics can lead to psychosocial difficulties and a decreased sense of self-worth. 36 , – 41 Although not all transgender individuals want surgery, treatment to help reduce the dissonance between physical body and gender identity has the potential to restore individuals’ sense of dignity and worth. In support of this goal, the ethics team recommended that the center provide services designed to meet patients’ psychosocial, emotional, and spiritual needs. This recommendation was addressed by the integration of a social worker with transgender health experience and training in the core team, who would explore patients’ motivations for surgery as part of the assessment ( Fig 2 ), and by the availability of transgender-affirming chaplaincy staff within the hospital. Center staff also determined that discussions of any surgical procedure should be instituted by the patient rather than offered by the team, to avoid giving the impression that providers felt any particular surgery was a necessary component of transition. The ethics team also recommended that center staff identify avenues for increasing understanding of the population served by the center, both within and outside the walls of BCH; fostering sensitivity and support throughout the center and the hospital for this population; and including input of this community into the development and operations of the center. In agreement with this goal, center staff have sought out opportunities to train providers and community members both inside and outside of the hospital 42 and continue to seek out opportunities to provide professional and community education whenever possible. This includes participation in the Care for Patients with Diverse Sexual Orientations and Gender Identities elective at Harvard Medical School and offering medical students opportunities to engage in additional research and practice with this population. The center has also sought input from community members and actively recruited transgender staff.

FIGURE 2. Patient care flow sheet. MD, medical doctor; NP, nurse practitioner; PA, physician’s assistant; SW, social worker.

Patient care flow sheet. MD, medical doctor; NP, nurse practitioner; PA, physician’s assistant; SW, social worker.

Respect for patient autonomy is the ethical principle that generated the most controversy when developing the center’s policies and practices for patient care. Questions of respect for patient autonomy are at the core of much of the debate around the current WPATH SOC and screening guidelines, specifically care structures that require behavioral health professionals to provide approval to access care rather than prioritizing access through a process of informed consent, a model that is being adopted more and more often for hormone treatment. 6 This is true not just in the adult setting, but in the pediatric setting, as well. Although the GeMS model requires extensive psychological screening, 30 other models are also in place for pediatric hormone access, 43 , 44 and the center sees patients who have taken various routes to medical transition.

Debate on this topic is not restricted to medical transition care. There is also substantial disagreement among providers and others as to whether the current guidelines requiring one or more mental health assessments for patients to move forward with gender affirmation surgeries are critical to providing quality care, are problematic gatekeeping, or are something in between. 45 , – 51 Because a clear answer to the appropriateness of these guidelines is not supported in the current evidence base, the center decided that the most-appropriate way to address the controversy would be to follow the SOC while researching the burdens and benefits of the behavioral health requirements, particularly with respect to providing services to adolescents. To date, the center has enrolled over 70 patients into a longitudinal study in which researchers are assessing quality of life, mental health, and issues and costs of health care access in the context of gender-affirming surgery.

A related issue was whether minors were able to provide informed assent to the kinds of procedures being offered. Addressing this issue is a required component of the outside letters of support needed to access surgery. In addition, it has been previously established that minors legally and ethically can provide informed consent, without parent permission, for many medical therapies related to sexual and mental health. 52  

Another issue raised around informed consent was specific to the pediatric population, namely the role of parents and guardians in providing informed consent (sometimes referred to as informed permission), because minors generally can provide assent but not consent for care. 52 There was substantial discussion among the ethics team, hospital counsel, and center providers as to whether the consent of both parents must be required for minor patients to undergo gender-affirming surgery. Although consent from both parents, alongside assent from the minor, is the standard for care in the hospital’s GeMS program, many transgender youth have complicated family situations. 32 , 53 , – 57 This may make acquiring 2-parent consent to perform surgery on an adolescent unfeasible or impossible, particularly when 1 parent is no longer involved in the minor’s life. Eventually, the center decided on a policy incorporating the standard of 2-parent consent but with the intention to develop formal procedures allowing for appeal in cases in which such a requirement appears to interfere unduly with the informed choices of minors and raises the possibility of significant harm.

Although for some people the requirements for parental consent and behavioral health assessment raised questions about the autonomy of adolescent patients, for others it was reassuring. There is substantial debate around adolescents’ capacity for decision-making and ability to conceptualize long-term outcomes. 58 , – 60 The involvement of both parents and multiple behavioral health providers in the process of determining eligibility for surgery, as well as the patients’ discussion with the interdisciplinary team of the benefits and risks (including possible regrets), serves as a check on the possibility of impulsivity and reduces the likelihood that age-related cognitive factors would lead to decision regret.

As such, the role of parents is not simply to provide informed consent. They are also important sources of insight and support throughout the gender affirmation process. Parental concerns can give important insights into adolescent maturity, gender stability, mental health, and well-being and provide a window into additional areas that the behavioral health provider might need to explore before surgical approval. Because of this, parent and guardian education is an important part of the consult process for minors seeking surgery, as is assessment of those adults’ interest in and willingness to support the patient through surgery. Situations in which parents disagree with each other are particularly challenging and addressed on a case-by-case basis.

Members of the ethics committee brought up a concern that some members of the public may have moral or religious objections to transgender surgery. Objections had been raised when the GeMS program was first started, including some death threats to staff, and it was thought that it would be important to prepare for any similar backlash in response to the start of the center. The possibility of moral or religious objections to surgery was not seen as a barrier to providing these services, and the ethics team recommended that appropriate hospital staff, including public relations staff, familiarize themselves with the nature of possible objections to the establishment of the center and with the underlying medical and ethical reasons for establishing the center to be able to engage in informed communication with the public. To accomplish this goal, center staff worked with marketing and communications staff at the hospital to develop evidenced-based messaging and responses to expected objections and to increase staff confidence with transgender issues. Center staff have also offered, and continue to provide in an ongoing manner, training to health care and support professionals throughout the hospital on both how to support patients and the importance of gender-affirming care for individual well-being.

The hospital has some existing policies related to religious and moral objections by staff. The personnel policy on “Requests to be excused from Patient Care Responsibilities,” for example, states that the hospital “will consider a request by a staff member not to participate in aspects of a patient’s care or treatment when such care or treatment conflicts with a staff member’s bona fide ethical or religious beliefs.” However, the policy is also clear that such a request cannot be accommodated if it will negatively affect care for the patient.

All participants involved in the discussions recognized the importance of education in addressing staff moral and religious concerns. To help accomplish this goal, center staff involved in education attempt to provide a safe space for questioning and discussion of care practices. 42 In addition, center staff are currently in the process of deploying a validated survey 61 to examine provider attitudes about and self-assessed competence in lesbian, gay, bisexual, and transgender health care across the hospital. It is suggested in the preliminary results that provider attitudes are primarily positive, although there were some responses expressing moral concerns about working with lesbian, gay, bisexual, and transgender patients and families. Results also suggest that providers were consistently less comfortable, and felt less competent, about working with transgender patients and families than lesbian, gay, and bisexual patients and families. 62 This is being addressed through offering increased opportunities for professional education on gender surgery and gender-affirming care throughout the hospital. Center staff offered more than 20 trainings to BCH staff between December 2017 and December 2018, and trainings continue to be requested across a variety of units and departments.

There is a documented unmet need for gender-affirming services, including surgical procedures. 32 , 63 , – 66 This was clearly visible in the fact that, within a few months of Boston Medical Center starting to offer insurance-covered vaginoplasty, their waitlist quickly grew to over 200 patients. 67 Because of the possibility of waitlists for the center’s services, the ethics team recommended that the center have a clear and consistent method of prioritizing patients for care. The center decided to take a first-come, first-served approach to initial consultation with patients. However, the center recognized there would be a need to undertake further exploration of methods for allocating resources in the event that limits were reached. From the beginning, center staff anticipated that hair removal would likely provide the primary scheduling barrier for patients seeking genital affirmation, and that has proven to be the case. (Hair removal is a requirement for genital surgery because of concerns about the presence of hair in the neourethra or neovagina.) Chest surgery scheduling is more straightforward and primarily limited by the availability of operating room time. While continuing to use the first come, first served principle, the center is working on ways to shorten waiting times whenever feasible.

After the initial ethical discussions were conducted, there remained several questions that the center wished to explore further. One such question was determining an appropriate age range for patients to be able to access each type of gender-affirming surgical procedure. Because the hospital is a pediatric institution, with policies about the age ranges for which it is appropriate to provide care, this discussion needed to address both the lower and upper bounds of care.

The WPATH SOC state that genital surgery should not be done until the age of majority in any given country (18 in the United States), but that it may be reasonable for chest surgeries to be done earlier. 3 Unfortunately, there is extremely limited published research on the impact of chest surgeries on the pediatric and young adult population. In what research there is, it is suggested that chest surgery can make it easier for young transmasculine individuals to participate more fully in society, including making it easier to exercise and maintain their health. 68 This research is supported by the clinical experience of center staff. Breast augmentation also has the potential to allow young transfeminine individuals to present more effectively as feminine, although fewer transfeminine than transmasculine individuals are interested in chest surgery. 32  

After weighing the guidelines and feedback from stakeholders, the center decided to deviate from the SOC and set 15 as a minimum age for undergoing a chest reconstruction or breast augmentation, with surgery at age 15 only being appropriate for those individuals who have had a strong and consistent gender identity and, in rare cases, those who are significantly limited in life activities by the presence of their breasts. Because the risk of desistence of a transgender identity declines sharply after puberty, 22 , 69 the center thought that this allowed for a reasonable balance of recognizing the possible risk of a premature decision with respecting patients’ current needs and preferences.

Determining the minimum age for genital surgeries was somewhat more complicated. Although all center staff felt comfortable with requiring phalloplasty candidates to wait until the age of majority for surgery, the same was not true for vaginoplasty candidates. Transgender women who have not undergone vaginoplasty may face a number of challenges related to the existential threat that is sometimes perceived to accrue through the presence of male genitalia in a women’s-only space. 42 This concern may be particularly salient for young transgender women who are going off to college and who want to live, and be treated, like any other young women on campus. As a result, a number of American surgeons perform vaginoplasty procedures in patients under the age of 18 to allow young women to begin their adult lives feeling safe and affirmed in their gender. 5 Although mental health outcomes associated with vaginoplasty have generally been shown to be quite positive, to date there have been few published studies specifically exploring the psychosocial outcomes of vaginoplasty in minors. 70 , 71 Two studies following the same small population of girls who underwent vaginoplasty during adolescence did report improved psychological functioning and decreased gender dysphoria at 1 and 5 years follow-up. 72 , 73  

However, performing vaginoplasty in patients under the age of 18 raises several particular concerns. 1 These include the ability of the patient to adequately provide assent 52 and a detailed assessment of whether the young woman will be capable of the extensive postsurgical care required by the procedure. 72 , 74 It is also critical to explicitly address the fact that the procedure will render the patient permanently sterile and attempt to determine whether the patient is capable of making an informed decision to permanently impact their fertility. Although fertility assessment is, in theory, a standard part of assessment earlier in the transition process, the center team felt it was critical to include such an assessment as part of the initial social work consult with every potential patient, regardless of age. This fertility assessment includes questions about whether the patient wants to have biological children, any history of gamete preservation, and appropriate referrals as necessary. The center team has found that doing such an assessment is critical because a sizeable minority of patients do not have a clear understanding of the fertility impacts of gender transition at the time of the initial consult.

The center staff eventually came to the conclusion that it is appropriate to offer vaginoplasties to certain individuals before the age of majority so that they can safely embark on their adult lives. However, to address legal concerns related to performing vaginoplasties in Massachusetts minors, it was necessary to institute a policy requiring such patients to either have undergone fertility preservation or to seek out a court order granting permission for surgery. To date, the only family to which this option has been offered has decided to pursue the court order.

Building a gender surgery center in a pediatric setting requires institutions to address unique ethical and legal challenges. It is important for providers and administrators to have a clear understanding of the local legal environment and relevant ethical principles. Plans for navigation of ethical challenges should be discussed early in the process, and institutions should plan to respond to ethical and moral considerations brought up by staff, patients, and the public at large. Ongoing ethical and legal consultation, as well as a broad range of staff, patient, and public educational opportunities, are likely to be needed. Such processes are necessary to provide optimal care for members of the transgender community in an ethically responsible fashion.

Dr Boskey copresented to the ethics committee, provided topic-specific documentation to the committee for review, drafted the manuscript, and oversaw all revisions; Ms Johnson led the drafting of the ethics committee response to the initial committee consultation, which was used in the drafting of the manuscript, and contributed significantly to revisions; Dr Harrison, Dr Marron, Ms Abecassis, Ms Scobie-Carroll, and Dr Willard contributed to the ethics committee consultation and contributed significantly to revisions; and Drs Diamond, Taghinia, and Ganor initiated the ethics consultation process, copresented to the ethics committee, worked on all consultations, and contributed significantly to revisions; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

The authors thank the members of Boston Children’s Hospital Ethics Advisory Committee for thoughtful comments and insights during their meeting to discuss this topic.

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The Ethical Intricacies of Transgender Surgery

A person on a blue and purple background with marking on their face

Illustration by Taimi Xu

Article by Leyla Giordano

Over the past decade, the transgender population has increased in visibility dramatically in the United States. The medical field has made progress when it comes to access to gender-affirming surgery; however, the progress has not rid society of discrimination and bias towards the transgender population, and access to care is still limited. Thus, it is essential to train medical professionals to care for this vulnerable population with compassion and knowledge. During the summer of 2018, I interned at the Gender Reassignment Department of Mount Sinai Hospital, where Dr. Jess Ting pioneered New York City’s first surgical program dedicated to transgender surgery. I learned that he transforms bodies every day in his operating room and cares for his patients with empathy, but he also struggles with feelings of helplessness when his patients share their devastating stories and disappointment when his surgeries are unable to live up to their expectations.

The American Psychiatric Association defines transgender as “a person whose sex assigned at birth (i.e. the sex assigned at birth, usually based on external genitalia) does not align with their gender identity (i.e., one’s psychological sense of their gender).” 1 Further, a subset of transgender individuals will experience gender dysphoria, defined by the American Psychiatric Association as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” 1 Thus, the dysphoria refers to the psychological distress that can often result from being transgender. In response to gender dysphoria, one may seek affirmations in several areas, including but not limited to social, legal, medical, or surgical. Medical and surgical affirmations are two ways in which one’s true identity can be revealed externally to society. Gender affirming surgery includes vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, and others. 3 Surgeries like these can help reduce an individual’s gender dysphoria so that their physical body matches their gender identity.

Overall, transgender surgery improves lives because it gives trans individuals a body in which they feel more like themselves. However, the transgender population faces significant disparities in social determinants of health. These detrimental determinants limit Dr. Ting’s ability to heal this vulnerable population, frustrating him as he is ultimately unable to fix the discriminatory social context they encounter outside of the hospital. This paper will first discuss what it means to be transgender and how Dr. Ting’s work improves their life experiences. It will then move into the broader traumas that transgender individuals face. Finally, this paper will discuss the limitations and frustrations of Dr. Ting’s practice and how they have affected his approach.

Being transgender in our society and life-changing surgery

Since the 1900s, historians, activists, anthropologists, and many others have engaged in the debate between sex and gender. The social presentation and embodiment of one’s gender can differ from the anatomy or chromosomes with which one is born. Until recently, people have assumed that females act feminine because they have a uterus, not because they identify as a “female.” Society has assigned certain characteristics to what it means to be a girl, such as wanting to wear lipstick and play with Barbies. In the 1960s, a white and Western feminist theory emerged that posits that sex refers to the natural anatomical features, whereas gender refers to the culturally constructed norms that have been built based on one’s sex. 2 This theory persisted into the 1990s, when Judith Butler argued that, in addition to gender, sex is also a social construct. She posited that if gender and sex are both social constructs, then these two terms are essentially the same. 2

For decades, long-standing ideologies have informed beliefs that the trans identity is unacceptable since it runs contrary to the societally constructed connection between sex and gender. However, individuals like Dr. Jess Ting are contributing to the current shift in that dialogue surrounding the acceptance of trans identities. The Gender Reassignment Department that Dr. Jess Ting helped create at Mount Sinai Hospital gives transgender individuals the medical care that they need, changing the discourse around the transgender identity from taboo to celebrated. For example, in an interview I conducted with Dr. Ting, he recounted a memory about his oldest patient, who has stayed with him for five years. She was 77 years old and had been married to a man for many years. She told Dr. Ting that “this [surgery] is something I want to do for myself. I’ve wanted it since I was five years old, and I have never been able to get it.” As soon as Dr. Ting began to sign her up for surgery, she began to cry. She said, “I thought you were going to tell me that I was too old for surgery.” This story has stuck with Dr. Ting ever since because, as he says, “it’s powerful to give someone something that they have wanted for their whole life.” This patient had previously not gone to a doctor for the surgery out of fear that she herself and her identity would never be accepted. She also never had access to surgery because until 2016, no surgical programs existed in the state of New York. However, at the age of 77, the discussion around the transgender population has become significantly more welcoming and access to these operations increased such that Dr. Ting’s patient was able to finally get the gender-affirming surgery for herself.

A significant number of Dr. Ting’s operations are facial feminization surgeries. Facial feminization surgery, which includes shaving the male protruding forehead and brow ridge and softening the nose and jaw, are sought out by transgender individuals who identify as women and hope to have society externally view them as women. It is difficult to masculinize a face, but facial feminization surgery is extremely effective in giving a patient the stereotypical female features, such as a less-protruding forehead. Society consistently puts pressure on each gender to embody certain characteristics, as Eric Plemons points out in The Look of a Woman : “Yes, [the operating room] was the precise location in which patients’ longed-for physical transformations took place. But it was also a place whose material dynamics pushed and pulled at conceptual frameworks of embodiment and selfhood that lay at the heart of trans-body projects.” 3 Dr. Ting revealed to me that the most common reaction he gets from his patients post-surgery is, “I just feel like me now,” as the material change in their appearance is an important part of what finally allows them to externally embody their ideal selves. Thus, the operating room becomes a place where the physical transformation makes it possible for a transgender individual to finally fit their own vision of themselves.

In a visual society such as ours, one’s facial features become the most salient factor in society’s recognition of one’s sex. As Plemons mentions, “Facial feminization surgery is guided by hope for future phenomenological integration and social recognition the creation of a body that (re)presents the self.” 3 Transgender individuals are unable to embody their ideal selves when they remain in the body they were given at birth. However, through facial feminization surgery, a transgender female can be outwardly recognized as a woman, making gendered embodiment a social phenomenon. As Rosalind expresses in Plemons’ article, “‘I’ve spent twenty-five years of my life thinking about not looking like I do now. I want that to go away. Constant thinking about that ruins the mind. After this I’ll be able to think of other things, everyday things.’” 3 Rosalind’s inability to embody her ideal self consumes her, as she is told every day by society that her gender identity is based off her recognizable characteristics like her Adam’s apple and her “Neanderthal brow.” 3 Facial feminization surgery is, thus, a popular way to experience the world in a body that is outwardly recognizable and accepted as female.

The stereotypical facial features of a woman are what have been defined as “normal” to society. These features include a softer brow ridge and forehead, eyebrows with a slight arch, fuller lips, no facial hair, and a smaller nose. Society defines these characteristics as female, and it also defines a binary of female and male as the only acceptable genders. According to Abramowitz’s three definitions of “normal,”—socially accepted or morally condoned, statistically most common, and frequently occurring in everyday life—each society determines that a specific anomaly is not “normal.” 4 Using these definitions, society sees transgender individuals as not “normal.” However, this is not how society should see the transgender population. This isolation is the exact disposition that leads to transphobia and a lack of transgender-specialized healthcare in the United States. Transgender individuals have reported that the most significant barrier to health care is the lack of physicians who are culturally competent and knowledgeable on the population. 5 Dr. Ting echoed this shortage when he discussed his introduction into the field: “When we started our program in 2016, there was no place in New York City to access transgender surgery.” Despite the discrimination they face, transgender individuals are normal and should be considered normal by society; they are simply human beings who do not feel comfortable in their own bodies. Through his work at Mount Sinai Hospital, Dr. Ting became a pioneer in this field of medicine, making the transition to an embodiment of transgender individuals’ ideal selves possible.

The broader traumas

Trans individuals’ health outcomes are negatively impacted through several factors, such as intense stigma, increased harassment, and restricted access to employment, healthcare, and insurance. The detrimental effect that these factors cause can extend as far as suicide. Dr. Ting revealed, “The thing that was most impactful for me was when we first started seeing patients. One of the patients that I had interviewed and was going to schedule for surgery killed themselves. And up until that moment, I did not understand what the trans experience meant. That’s how I came to understand why these surgeries can be lifesaving.” Despite the beneficial impact of transgender surgery, it cannot rid the United States of its unequal structural and social determinants of health. Transgender individuals often have restricted access to employment, healthcare, and housing compared to cisgender individuals. 6 Dr. Ting mentioned in our interview, “So many of my patients are sex workers, are undomiciled, and are living in shelters. This made me realize that I was judgmental. There’s not much that separates us from people who live on the streets or who are sex workers. When you have no other options, that is your only way of surviving.” The lack of these fundamental resources can lead to increased stress and poor physical and mental health, such as depression, suicidality, and chronic illnesses. 6

The othering of the transgender population leads to an intense and detrimental stigma surrounding the trans identity. Transgender individuals experience structural stigma (societal norms), interpersonal stigma (verbal harassment, physical violence, sexual assault), and individual stigma (the feelings these individuals hold about themselves that may shape future behavior such as the anticipation of discrimination). Structural stigma originates from the socially constructed gender binary, and therefore marginalizes those that are considered “abnormal.” This stigma may “therefore operate as a form of symbolic violence in which structures, such as communities, institutions, or governments, […] restrict and forcibly reshape transgender individuals in ways that ultimately serve to maintain the power and privilege of the cisgender majority.” 6 For example, a lack of insurance within the transgender population may lead trans individuals to pay out of pocket for procedures, which therefore makes it more likely that they feel they have no option other than to use cheaper street hormones acquired through friends or online. 6 Secondly, interpersonal stigma refers to the increased levels of physical and sexual harassment:“It is theorized that gender nonconformity causes perpetrators of violence to become anxious and angry, ultimately enacting violence against transgender people as a means of rejecting and diminishing that which they fear.” 6 Further, a national survey showed that, out of 402 transgender individuals, 47% had been assaulted and 14% of the 47% had been raped or survived attempted rape. 7 Thus, transgender individuals experience disproportionate abuse in their lifetimes, whether that be in the form of hate crimes, sexual assault, or verbal abuse. Finally, individual stigma refers to transgender individuals’ negative image of themselves. This stigma makes them anxious to seek out healthcare and destroys their ability to deal with external stressors, leading to an increase in preventable deaths such as suicide.

Another crucial example of  negative health outcomes among the transgender population is the increased rate of HIV. According to the Journal of Virus Eradication , “transgender women have a pooled HIV prevalence of 19.1%, […] For transgender women sex workers, HIV prevalence is even greater, estimated at 27.3%.” 8 Researchers believe that the increased risk is multifactorial and may be “due to differing psychosocial risk factors, poorer access to transgender-specific healthcare, a higher likelihood of using exogenous hormones or fillers without direct medical supervision, interactions between hormonal therapy and antiretroviral therapy, and direct effects of hormonal therapy on HIV acquisition and immune control.” 8 The fear of the medical setting that is present in the transgender population could lead to decrease testing for sexually transmitted infections, and therefore higher rates of HIV. Additionally, the stigma that surrounds the trans population leads to an alarming amount of trans individuals going into sex work due to the absence of other employment opportunities, which could also lead to increased levels of HIV.

The aforementioned factors contribute to a symbolic violence in which transgender individuals internalize the social asymmetries they experience. 9 This internalization can lead to a reactive personality and may even culminate in a personality disorder such as borderline personality disorder, since transgender individuals become used to the abuse and thus have learned to fight for themselves. As Dr. Ting reflected, “When anything goes wrong, [my patients’] reactions can be overwhelming and out of proportion to what you would expect. They blow up at me all the time. […] Trans people have a lived experience where […] they are subjected to abuse, and they are ignored. When you live like that, you build up your fences and you learn that you have to fight and scream for just regular occurrences.” Every day, Dr. Ting sees first-hand the internalization of the stigma that the transgender population faces. Trans individuals begin to view themselves and their self-worth through how they are negatively treated, prompting the development of a personality that is programmed to protect oneself against the world.

Limitations of Dr. Ting’s practice and their effects

The discrimination and abuse that Dr. Ting’s patients experience often exceed the medical realm, so an approach that focuses on narrative medicine and listening to his patients’ personal stories is important. 10 In “Narrative Medicine: Attention, Representation, Affiliation,” Rita Charon moves past the narrow focus on her patients’ physical bodies and approaches her patients with a dedication to their stories. 11 As Charon writes about a patient, “It was not just a matter of my having to know which section of his brain infarcted in his stroke but also what his stroke made of him, what it did to him, how he fought back from it, […] whether he will be the person he once was. It mattered to him and to our future clinical relationship that I know these things, that I have heard his fears and rage and grieving.” 11 Similarly, Dr. Ting is committed to listening to his patients’ personal stories about their experiences as transgender individuals. In our interview, he emphasized how important it was to him to listen to his patients and their concerns, as his patients often lack a support system. In this way, similarly to Dr. Charon, Dr. Ting acts as an empathic witness for his suffering patients. 10

However, physicians can only open themselves up to others’ suffering to a certain extent, and this balance has been difficult for Dr. Ting. When his patients come to his office, they have looked forward to their gender-affirming surgery for years, putting immense pressure on the outcome. This pressure can also lead to a dependency on the physician after a successful surgery for further help; however, Dr. Ting can only accept so much responsibility. During our interview, Dr. Ting reflected on a close relationship he built with one of his patients that caused him a large amount of grief: “One of my patients killed himself. He didn’t have a very smooth postoperative course. During Thanksgiving, he was texting me and meeting with a urologist. The urologist didn’t like the way that this patient was speaking to him. He can be a little rough, and the urologist [denied him care]. He then texted me saying, ‘What am I going to do now?’ I remember that I was out of town, and I responded ‘Don’t worry, we’ll find you someone else. It’s going to be okay.’ And he texted a few more times on Thursday or Friday, and then over the weekend, I noticed that I hadn’t heard from him in a while. I texted him on Monday to ask how he was doing, and I never heard back. A few days later, I found out that he had killed himself on the Monday after Thanksgiving.” With this news, Dr. Ting blamed himself, thinking that it was the complications from his surgery that made his patient commit suicide.

Physicians around the country experience burnout from job demands such as an overwhelming workload and emotional demands. Research on the mental health of psychologists and other physicians shows that these occupations aim to help people in need, leading to a high level of responsibility and increased emotional and interpersonal stressors for the physicians themselves. 12 Dr. Ting could not help but assign blame to himself for his patient’s suicide. In the process of doing so, the high level of compassion and empathy required of him negatively affected Dr. Ting. For psychologists, emotional exhaustion is the most commonly reported cause of burnout. 12 Although Dr. Ting is not a psychologist, his patients often depend on him for matters that extend past his office due to their lack of a support system. Dr. Ting provides life-changing surgeries to a very vulnerable population and deeply cares about his patients, and that type of work requires high levels of involvement, which can lead to burnout. As a consequence of burnout, research has shown that physicians then “seek an escape or distance themselves from their work both emotionally and cognitively, and [the burnout] is thought to lead on to feelings of cynicism.” 12 Dr. Ting felt himself burning out from the emotional burden he experienced while forming close relationships with his patients, and it forced him to place distance between him and his patients.

Thus, especially after his patient’s suicide, Dr. Ting decided to set a boundary between him and his patients by strictly keeping his relationships to his office. It was necessary for Dr. Ting to adopt a medical gaze to take care of himself. 13 In the process, he lamented the loss of the personal relationships he had built:

In the beginning, I would find myself getting very close to patients, sharing lots of details of their lives. In a way, that was really gratifying and rewarding for them to share emotionally fraught things. That’s why you become a healer. You want to heal people, and part of that is the positive feedback you get back from patients. Over time, I found that 99% of patients would be great, but the one complication would take so much out of me mentally. I could feel myself burning out a lot, so now, I am much more careful with patients in terms of creating boundaries. I don’t get as close to patients, which is sad, but it is necessary to protect myself. When I go see patients after surgery, and they tell me that I changed their lives, [saying] “How can I ever thank you?”, I feel like I have become a little numb to that, and I put up the boundaries where I’m afraid to let myself get close with patients.

Dr. Ting struggles between his commitment to his patients on a personal level and protecting himself from extreme responsibility for his patients’ distress. This complicated experience unfortunately limits the extent of his care. Despite the loss of many relationships that he values and his commitment to his patients past their physical bodies, Dr. Ting finds himself having to take a step back to separate himself from the burden of his patients’ trauma.

Overall, Dr. Ting changes his patients’ lives by giving them a body they can finally love and claim as their own. However, this responsibility brings a lot of pressure, as Dr. Ting expressed in our interview: “There is this tendency to idealize what’s going to happen or to feel like this surgery will cure everything – it will cure ‘all my ails.’ It doesn’t do that, it doesn’t cure all the ails of society – it makes your body align better with your internal identity, but you still have to go out into the world, and the world is not a better place.” Dr. Ting’s contributions to the transgender community supersede all expectations and grant so many the bodies and comfort they so desperately need, but he himself cannot change the society that transgender individuals enter back into when they leave the hospital. Despite the intense grief that Dr. Ting conveyed when he talked about the suicide of a patient and close friend, he ended our interview by relaying an encouraging conversation he had with his late patient’s partner: “She told me that the patient loved the body that I made for him, even with the complications. She told me that if he hadn’t had that surgery earlier, he would’ve died even sooner. He would not have even lived this long. For me, that lifted a heavy burden. I realized that maybe it wasn’t my fault, and that I did help him.” It’s clear that to Dr. Ting, the complicated moral experience that he faces within and beyond his office is worth it when he can aid individuals  that are so desperately in need of his care.

  • “What is Gender Dysphoria?” American Psychiatric Association . https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria
  • Mason, Katherine. “Embodiment.” (Brown University, February 14, 2022).
  • Plemons, Eric. “The Operating Room | The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine | Books Gateway | Duke University Press,” Chapter 5.
  • Mason, Katherine. “The Normal and the Abnormal.” (Brown University, February 7, 2022).
  • Safer, Joshua D., Eli Coleman, Jamie Feldman, Robert Garofalo, Wylie Hembree, Asa Radix, and Jae Sevelius. “Barriers to health care for transgender individuals.” Current opinion in endocrinology, diabetes, and obesity 23, no. 2 (2016): 168-171. 10.1097/MED.0000000000000227
  • White Hughto, Jaclyn M., Sari L. Reisner, and John E. Pachankis. “Transgender Stigma and Health: A Critical Review of Stigma Determinants, Mechanisms, and Interventions.” Social Science & Medicine 147 (December 1, 2015): 222–31. https://doi.org/10.1016/j.socscimed.2015.11.010 .
  • Mizock, Lauren, and Thomas K. Lewis. “Trauma in Transgender Populations: Risk, Resilience, and Clinical Care.” Journal of Emotional Abuse 8, no. 3 (August 26, 2008): 335–54. https://doi.org/10.1080/10926790802262523 .
  • Wansom, Tanyaporn, Thomas E. Guadamuz, and Sandhya Vasan. “Transgender Populations         and HIV: Unique Risks, Challenges and Opportunities.” Journal of Virus Eradication 2, no. 2 (April 1, 2016): 87–93. https://doi.org/10.1016/S2055-6640(20)30475-1 .
  • Mason, Katherine. “Narrative, Stories, and Healing.” (Brown University, February 23, 2022).
  • Charon, Rita. “Narrative Medicine: Attention, Representation, Affiliation.” Narrative 13, no. 3 (2005): 261-270. https://library.brown.edu/reserves/pdffiles/55716_rita_charon.pdf .
  • McCormack, Hannah M., Tadhg E. MacIntyre, Deirdre O’Shea, Matthew P. Herring, and Mark J. Campbell. “The prevalence and cause (s) of burnout among applied psychologists: A systematic review.” Frontiers in psychology (2018): 1897. https://doi.org/10.3389/fpsyg.2018.01897
  • Mason, Katherine. “(Bio)medical Training and Professions.” (Brown University, March 7, 2022).

Nigel Barber Ph.D.

The Gender Reassignment Controversy

When people opt for surgery, are they satisfied with the outcome.

Posted March 16, 2018 | Reviewed by Ekua Hagan

In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?

Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.

These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.

Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.

The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.

The Money Perspective

Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.

Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.

Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).

Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.

Adult Reassignment Surgery Motivation

Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.

In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.

McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.

If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.

To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.

Adult Reassignment Results

Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman ( Tootsie ). Diligent as the actor was in his preparation, his character looked masculine.

For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”

According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:

“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.

gender reassignment ethical issues

Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.

What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.

McHugh's views are associated with the religious right-wing that has lost ground in this area.

Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.

Aspirational Surgery

Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).

Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.

The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).

All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.

2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.

3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden . Plos One.

Nigel Barber Ph.D.

Nigel Barber, Ph.D., is an evolutionary psychologist as well as the author of Why Parents Matter and The Science of Romance , among other books.

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13.1 The ethics of gender reassignment surgery

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Transgender issues are very much in the news at present. There has been discussion about both gender dysphoria in general but, more specifically, the practical, psychological, and financial implications of carrying out gender reassignment surgery. In the United Kingdom, this extends to a debate on whether it is justifiable to carry out these procedures within an already hard-pressed National Health Service. This chapter discusses the nature, history, and background of both gender dysphoria and gender reassignment surgery and whether such procedures are justifiable in terms of outcomes and patient satisfaction; and also whether these are legitimate procedures to carry out within the National Health Service.

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David Reimer and John Money Gender Reassignment Controversy: The John/Joan Case

In the mid-1960s, psychologist John Money encouraged the gender reassignment of David Reimer, who was born a biological male but suffered irreparable damage to his penis as an infant. Born in 1965 as Bruce Reimer, his penis was irreparably damaged during infancy due to a failed circumcision. After encouragement from Money, Reimer’s parents decided to raise Reimer as a girl. Reimer underwent surgery as an infant to construct rudimentary female genitals, and was given female hormones during puberty. During childhood, Reimer was never told he was biologically male and regularly visited Money, who tracked the progress of his gender reassignment. Reimer unknowingly acted as an experimental subject in Money’s controversial investigation, which he called the John/Joan case. The case provided results that were used to justify thousands of sex reassignment surgeries for cases of children with reproductive abnormalities. Despite his upbringing, Reimer rejected the female identity as a young teenager and began living as a male. He suffered severe depression throughout his life, which culminated in his suicide at thirty-eight years old. Reimer, and his public statements about the trauma of his transition, brought attention to gender identity and called into question the sex reassignment of infants and children.

Bruce Peter Reimer was born on 22 August 1965 in Winnipeg, Ontario, to Janet and Ron Reimer. At six months of age, both Reimer and his identical twin, Brian, were diagnosed with phimosis, a condition in which the foreskin of the penis cannot retract, inhibiting regular urination. On 27 April 1966, Reimer underwent circumcision, a common procedure in which a physician surgically removes the foreskin of the penis. Usually, physicians performing circumcisions use a scalpel or other sharp instrument to remove foreskin. However, Reimer’s physician used the unconventional technique of cauterization, or burning to cause tissue death. Reimer’s circumcision failed. Reimer’s brother did not undergo circumcision and his phimosis healed naturally. While the true extent of Reimer’s penile damage was unclear, the overwhelming majority of biographers and journalists maintained that it was either totally severed or otherwise damaged beyond the possibility of function.

In 1967, Reimer’s parents sought the help of John Money, a psychologist and sexologist who worked at the Johns Hopkins Hospital in Baltimore, Maryland. In the mid twentieth century, Money helped establish the views on the psychology of gender identities and roles. In his academic work, Money argued in favor of the increasingly mainstream idea that gender was a societal construct, malleable from an early age. He stated that being raised as a female was in Reimer’s interest, and recommended sexual reassignment surgery. At the time, infants born with abnormal or intersex genitalia commonly received such interventions.

Following their consultation with Money, Reimer’s parents decided to raise Reimer as a girl. Physicians at the Johns Hopkins Hospital removed Reimer’s testes and damaged penis, and constructed a vestigial vulvae and a vaginal canal in their place. The physicians also opened a small hole in Reimer’s lower abdomen for urination. Following his gender reassignment surgery, Reimer was given the first name Brenda, and his parents raised him as a girl. He received estrogen during adolescence to promote the development of breasts. Throughout his childhood, Reimer was not informed about his male biology.

Throughout his childhood, Reimer received annual checkups from Money. His twin brother was also part of Money’s research on sexual development and gender in children. As identical twins growing up in the same family, the Reimer brothers were what Money considered ideal case subjects for a psychology study on gender. Reimer was the first documented case of sex reassignment of a child born developmentally normal, while Reimer’s brother was a control subject who shared Reimer’s genetic makeup, intrauterine space, and household.

During the twin’s psychiatric visits with Money, and as part of his research, Reimer and his twin brother were directed to inspect one another’s genitals and engage in behavior resembling sexual intercourse. Reimer claimed that much of Money’s treatment involved the forced reenactment of sexual positions and motions with his brother. In some exercises, the brothers rehearsed missionary positions with thrusting motions, which Money justified as the rehearsal of healthy childhood sexual exploration. In his Rolling Stone interview, Reimer recalled that at least once, Money photographed those exercises. Money also made the brothers inspect one another’s pubic areas. Reimer stated that Money observed those exercises both alone and with as many as six colleagues. Reimer recounted anger and verbal abuse from Money if he or his brother resisted orders, in contrast to the calm and scientific demeanor Money presented to their parents. Reimer and his brother underwent Money’s treatments at preschool and grade school age. Money described Reimer’s transition as successful, and claimed that Reimer’s girlish behavior stood in stark contrast to his brother’s boyishness. Money reported on Reimer’s case as the John/Joan case, leaving out Reimer’s real name. For over a decade, Reimer and his brother unknowingly provided data that, according to biographers and the Intersex Society of North America, was used to reinforce Money’s theories on gender fluidity and provided justification for thousands of sex reassignment surgeries for children with abnormal genitals.

Contrary to Money’s notes, Reimer reports that as a child he experienced severe gender dysphoria, a condition in which someone experiences distress as a result of their assigned gender. Reimer reported that he did not identify as a girl and resented Money’s visits for treatment. At the age of thirteen, Reimer threatened to commit suicide if his parents took him to Money on the next annual visit. Bullied by peers in school for his masculine traits, Reimer claimed that despite receiving female hormones, wearing dresses, and having his interests directed toward typically female norms, he always felt that he was a boy. In 1980, at the age of fifteen, Reimer’s father told him the truth about his birth and the subsequent procedures. Following that revelation, Reimer assumed a male identity, taking the first name David. By age twenty-one, Reimer had received testosterone therapy and surgeries to remove his breasts and reconstruct a penis. He married Jane Fontaine, a single mother of three, on 22 September 1990.

In adulthood, Reimer reported that he suffered psychological trauma due to Money’s experiments, which Money had used to justify sexual reassignment surgery for children with intersex or damaged genitals since the 1970s. In the mid-1990s, Reimer met Milton Diamond, a psychologist at the University of Hawaii, in Honolulu, Hawaii, and academic rival of Money. Reimer participated in a follow-up study conducted by Diamond, in which Diamond cataloged the failures of Reimer’s transition.

In 1997, Reimer began speaking publicly about his experiences, beginning with his participation in Diamond’s study. Reimer’s first interview appeared in the December 1997 issue of Rolling Stone magazine. In interviews, and a later book about his experience, Reimer described his interactions with Money as torturous and abusive. Accordingly, Reimer claimed he developed a lifelong distrust of hospitals and medical professionals.

With those reports, Reimer caused a multifaceted controversy over Money’s methods, honesty in data reporting, and the general ethics of sex reassignment surgeries on infants and children. Reimer’s description of his childhood conflicted with the scientific consensus about sex reassignment at the time. According to NOVA, Money led scientists to believe that the John/Joan case demonstrated an unreservedly successful sex transition. Reimer’s parents later blamed Money’s methods and alleged surreptitiousness for the psychological illnesses of their sons, although the notes of a former graduate student in Money’s lab indicated that Reimer’s parents dishonestly represented the transition’s success to Money and his coworkers. Reimer was further alleged by supporters of Money to have incorrectly recalled the details of his treatment. On Reimer’s case, Money publicly dismissed his criticism as antifeminist and anti-trans bias, but, according to his colleagues, was personally ashamed of the failure.

In his early twenties, Reimer attempted to commit suicide twice. According to Reimer, his adult family life was strained by marital problems and employment difficulty. Reimer’s brother, who suffered from depression and schizophrenia, died from an antidepressant drug overdose in July of 2002. On 2 May 2004, Reimer’s wife told him that she wanted a divorce. Two days later, at the age of thirty-eight, Reimer committed suicide by firearm.

Reimer, Money, and the case became subjects of numerous books and documentaries following the exposé. Reimer also became somewhat iconic in popular culture, being directly referenced or alluded to in the television shows Chicago Hope , Law & Order , and Mental . The BBC series Horizon covered his story in two episodes, “The Boy Who Was Turned into a Girl” (2000) and “Dr. Money and the Boy with No Penis” (2004). Canadian rock group The Weakerthans wrote “Hymn of the Medical Oddity” about Reimer, and the New York-based Ensemble Studio Theatre production Boy was based on Reimer’s life.

  • Carey, Benedict. “John William Money, 84, Sexual Identity Researcher, Dies.” New York Times , 11 July 2016.
  • Colapinto, John. "The True Story of John/Joan." Rolling Stone 11 (1997): 54–73.
  • Colapinto, John. As Nature Made Him: The Boy who was Raised as a Girl . New York: HarperCollins Publishers, 2000.
  • Colapinto, John. "Gender Gap—What were the Real Reasons behind David Reimer’s Suicide." Slate (2004).
  • Dr. Money and the Boy with No Penis , documentary, written by Sanjida O’Connell (BBC, 2004), Film.
  • The Boy Who Was Turned Into a Girl , documentary, directed by Andrew Cohen (BBC, 2000.), Film.
  • “Who was David Reimer (also, sadly, known as John/Joan)?” Intersex Society of North America . http://www.isna.org/faq/reimer (Accessed October 31, 2017).

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Americans’ complex views on gender identity and transgender issues, most favor protecting trans people from discrimination, but fewer support policies related to medical care for gender transitions; many are uneasy with the pace of change on trans issues.

Pew Research Center conducted this study to better understand Americans’ views about gender identity and people who are transgender or nonbinary. These findings are part of a larger project that includes findings from six focus groups on  the experiences and views of transgender and nonbinary adults  and estimates of the  share of U.S. adults who say their gender is different from the sex they were assigned at birth . 

This analysis is based on a survey of 10,188 U.S. adults. The data was collected as a part of a larger survey conducted May 16-22, 2022. Everyone who took part is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way, nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the  ATP’s methodology . See here to read more about the  questions used for this report and the report’s methodology .

References to White, Black and Asian adults include only those who are not Hispanic and identify as only one race. Hispanics are of any race.

All references to party affiliation include those who lean toward that party. Republicans include those who identify as Republicans and those who say they lean toward the Republican Party. Democrats include those who identify as Democrats and those who say they lean toward the Democratic Party.

References to college graduates or people with a college degree comprise those with a bachelor’s degree or more. “Some college” includes those with an associate degree and those who attended college but did not obtain a degree.

The terms “transgender” and “trans” are used interchangeably throughout this report to refer to people whose gender is different from the sex they were assigned at birth.

A chart showing Most favor protecting trans people from discrimination, even as growing share say gender is determined by sex at birth

As the United States addresses issues of transgender rights and the broader landscape around gender identity continues to shift, the American public holds a complex set of views around these issues, according to a new Pew Research Center survey.

Roughly eight-in-ten U.S. adults say there is at least some discrimination against transgender people in our society, and a majority favor laws that would protect transgender individuals from discrimination in jobs, housing and public spaces. At the same time, 60% say a person’s gender is determined by their sex assigned at birth, up from 56% in 2021 and 54% in 2017.

The public is divided over the extent to which our society has accepted people who are transgender: 38% say society has gone too far in accepting them, while a roughly equal share (36%) say society hasn’t gone far enough. About one-in-four say things have been about right. Underscoring the public’s ambivalence around these issues, even among those who see at least some discrimination against trans people, a majority (54%) say society has either gone too far or been about right in terms of acceptance.

The fundamental belief about whether gender can differ from sex assigned at birth is closely aligned with opinions on transgender issues. Americans who say a person’s gender  can  be different from their sex at birth are more likely than others to see discrimination against trans people and a lack of societal acceptance. They’re also more likely to say that our society hasn’t gone far enough in accepting people who are transgender. But even among those who say a person’s gender is determined by their sex at birth, there is a diversity of viewpoints. Half of this group say they would favor laws that protect trans people from discrimination in certain realms of life. And about one-in-four say forms and online profiles should include options other than “male” or “female” for people who don’t identify as either.   

Related:  The Experiences, Challenges and Hopes of Transgender and Nonbinary U.S. adults

Chart showing Young adults, Democrats more likely to say society hasn’t gone far enough in accepting people who are transgender

When it comes to issues surrounding gender identity, young adults are at the leading edge of change and acceptance. Half of adults ages 18 to 29 say someone can be a man or a woman even if that differs from the sex they were assigned at birth. This compares with about four-in-ten of those ages 30 to 49 and about a third of those 50 and older. Adults younger than 30 are also more likely than older adults to say society hasn’t gone far enough in accepting people who are transgender (47% vs. 39% of 30- to 49-year-olds and 31% of those 50 and older) 

These views differ even more sharply by partisanship. Democrats and those who lean to the Democratic Party are more than four times as likely as Republicans and Republican leaners to say that a person’s gender can be different from the sex they were assigned at birth (61% vs. 13%). Democrats are also much more likely than Republicans to say our society hasn’t gone far enough in accepting people who are transgender (59% vs. 10%). For their part, 66% of Republicans say society has gone  too far  in accepting people who are transgender.

Amid a national conversation over these issues, many states are considering or have put in place  laws or policies  that would directly affect the lives of transgender and nonbinary people – that is, those who don’t identify as a man or a woman. Some of these laws would limit protections for transgender and nonbinary people; others are aimed at safeguarding them. The survey finds that a majority of U.S. adults (64%) say they would favor laws that would protect transgender individuals from discrimination in jobs, housing and public spaces such as restaurants and stores. But there is also a fair amount of support for specific proposals that would limit how trans people can participate in certain activities and navigate their day-to-day lives. 

Roughly six-in-ten adults (58%) favor proposals that would require transgender athletes to compete on teams that match the sex they were assigned at birth (17% oppose this, 24% neither favor nor oppose). 1 And 46% favor making it illegal for health care professionals to provide someone younger than 18 with medical care for a gender transition (31% oppose). The public is more evenly split when it comes to making it illegal for public school districts to teach about gender identity in elementary schools (41% favor and 38% oppose) and investigating parents for child abuse if they help someone younger than 18 get medical care for a gender transition (37% favor and 36% oppose). Across the board, views on these policies are deeply divided by party. 

Views of laws and policies related to transgender issues differ widely by party

When asked what has influenced their views on gender identity – specifically, whether they believe a person can be a different gender than the sex they were assigned at birth – those who believe gender can be different from sex at birth and those who do not point to different factors. For the former group, the most influential factors shaping their views are what they’ve learned from science (40% say this has influenced their views a great deal or a fair amount) and knowing someone who is transgender (38%). Some 46% of those who say gender is determined by sex at birth also point to what they’ve learned from science, but this group is far more likely than those who say a person’s gender can be different from their sex at birth to say their religious beliefs have had at least a fair amount of influence on their opinion (41% vs. 9%).   

The nationally representative survey of 10,188 U.S. adults was conducted May 16-22, 2022.  Previously published findings from the survey  show that 1.6% of U.S. adults are trans or nonbinary, and the share is higher among adults younger than 30. More than four-in-ten U.S. adults know someone who is trans and 20% know someone who is nonbinary. Among the other key findings in this report:

Nearly half of U.S. adults (47%) say it’s extremely or very important to use a person’s new name if they transition to a gender that is different from the sex they were assigned at birth and change their name.  A smaller share (34%) say the same about using someone’s new pronouns (such as “he” instead of “she”). A majority of Democrats (64%) – compared with 28% of Republicans – say it’s at least very important to use someone’s new name if they go through a gender transition and change their name. And while 51% of Democrats say it’s extremely or very important to use someone’s new pronouns, just 14% of Republicans say the same.

Many Americans express discomfort with the pace of change around issues of gender identity.  Some 43% say views on issues related to people who are transgender or nonbinary are changing too quickly, while 26% say things aren’t changing quickly enough and 28% say the pace of change is about right. Adults ages 65 and older are the most likely to say views on these issues are changing too quickly; conversely, those younger than 30 are the most likely to say they’re not changing quickly enough. 

More than four-in-ten (44%) say forms and online profiles that ask about a person’s gender should include options other than “male” and “female” for people who don’t identify as either.  Some 38% say the same about government documents such as passports and driver’s licenses. Half of adults younger than 30 say government documents that ask about a person’s gender should provide more than two gender options, compared with about four-in-ten or fewer among those in older age groups. Views differ even more widely by party: While majorities of Democrats say forms and online profiles (64%) and government documents (58%) should offer options other than “male” and “female,” about eight-in-ten Republicans say they should  not  (79% say this about forms and online profiles and 83% say this about government documents). 

Democrats and Republicans who agree that a person’s gender is determined by their sex at birth often have different views on transgender issues.  A majority (61%) of Democrats – but just 31% of Republicans – who say a person’s gender is determined by the sex they were assigned at birth say there is at least a fair amount of discrimination against transgender people in our society today. And while 62% of Democrats who say gender is determined by sex at birth say they would favor policies that protect trans individuals against discrimination, fewer than half of their Republican counterparts say the same. 

Democrats’ views on some transgender issues vary by age.  Among Democrats younger than 30, about seven-in-ten (72%) say someone can be a man or a woman even if that’s different from the sex they were assigned at birth, and 66% say society hasn’t gone far enough in accepting people who are transgender. Smaller majorities of Democrats 30 and older express these views. Age is less of a factor among Republicans. In fact, similar shares of Republicans ages 18 to 29 and those 65 and older say a person’s gender is determined by their sex at birth (88% each) and that society has gone too far in accepting people who are transgender (67% of Republicans younger than 30 and 69% of those 65 and older).  

About three-in-ten parents of K-12 students (29%) say at least one of their children has learned about people who are transgender or nonbinary from a teacher or another adult at their school.  Similar shares across regions and in urban, suburban and rural areas say their children have learned about this in school, as do similar shares of Republican and Democratic parents. Views on whether it’s good or bad that their children have or haven’t learned about people who are trans or nonbinary at school vary by party and by children’s age. For example, among parents of children in elementary school, 45% say either that their children  have  learned about this and that’s a  bad  thing or that they  haven’t  learned about it and that’s a  good  thing. A smaller share of parents of middle and high schoolers (34%) say the same. Republican parents are much more likely than Democratic parents to say this, regardless of their child’s age.

A rising share say a person’s gender is determined by their sex at birth

Majority of U.S. adults say gender is determined by sex assigned at birth

Six-in-ten U.S. adults say that whether a person is a man or a woman is determined by their sex assigned at birth. This is up from 56%  one year ago  and 54% in  2017 . No single demographic group is driving this change, and patterns in who is more likely to say this are similar to what they were in past years.

Today, half or more in all age groups say that gender is determined by sex assigned at birth, but this is a less common view among younger adults. Half of adults younger than 30 say this, lower than the 60% of 30- to 49-year-olds who say the same. Even higher shares of those 50 to 64 (66%) and those 65 and older (64%) say a person’s gender is determined by their sex at birth.

The party gap on this issue remains wide. The vast majority of Republicans and those who lean toward the GOP say gender is determined by sex assigned at birth (86%), compared with 38% of Democrats and Democratic leaners. Most Democrats say that whether a person is a man or a woman can be different from their sex at birth (61% vs. just 13% of Republicans). Liberal Democrats are particularly likely to hold this view – 79% say a person’s gender can be different from sex at birth, compared with 45% of moderate or conservative Democrats. Meanwhile, 92% of conservative Republicans say gender is determined by sex at birth and 74% of moderate or liberal Republicans agree.

Democrats ages 18 to 29 are also substantially more likely than older Democrats to say that someone’s gender can be different from their sex assigned at birth, although majorities of Democrats across age groups share this view. About seven-in-ten Democrats younger than 30 say this (72%), compared with about six-in-ten or fewer in the older age groups. Among Republicans, there is no clear pattern by age. About eight-in-ten or more Republicans across age groups – including 88% each among those ages 18 to 29 and those 65 and older – say a person’s gender is determined by their sex at birth. 

The view that a person’s gender is determined by their sex assigned at birth is more common among those with lower levels of educational attainment and those living in rural areas or in the Midwest or South. This view is also more prevalent among men and Black Americans. 

A solid majority of those who do  not  know a transgender person say that whether a person is a man or a woman is determined by sex assigned at birth (68%), while those who  do  know a trans person are more evenly split. About half say gender is determined by sex assigned at birth (51%), while 48% say gender and sex assigned at birth can be different. 

Though Republicans who know a trans person are more likely than Republicans who don’t to say gender can be different from sex assigned at birth, more than eight-in-ten in both groups (83% and 88%, respectively) say gender is determined by sex at birth. Meanwhile, there are large differences between Democrats who do and do  not  know a transgender person. A majority of Democrats who  do  know a trans person (72%) say someone can be a man or a woman even if that differs from their sex assigned at birth, while those who don’t know anyone who is transgender are about evenly split (48% say gender is determined by sex assigned at birth while 51% say it can be different). 

Many Americans point to science when asked what has influenced their views on whether gender can differ from sex assigned at birth

When asked about factors that have influenced their views about whether someone’s gender can be different from the sex they were assigned at birth, 44% say what they’ve learned from science has had a great deal or a fair amount of influence. About three-in-ten (28%) point to their religious views and about two-in-ten (22%) say knowing someone who is transgender has influenced their views at least a fair amount. Smaller shares say what they’ve heard or read in the news (15%) or on social media (14%) has had a great deal or a fair amount of influence on their views.

Chart showing More than four-in-ten U.S. adults say science has influenced their views of gender and sex at least a fair amount

The factors people point to on this topic differ by whether or not they say gender is determined by sex at birth. Among those who say that whether someone is a man or a woman is determined by the sex they were assigned at birth, 46% say what they’ve learned from science has influenced their views on this at least a fair amount, while 41% say the same about their religious views. About one-in-ten point to what they’ve heard or read in the news (12%), what they’ve heard or read on social media (11%) or knowing someone who’s transgender (11%). 

Among those who say someone can be a man or a woman even if that’s different from the sex they were assigned at birth, 40% say their views on this topic have been influenced at least a fair amount by what they’ve learned from science. A similar share say the same about knowing a transgender person (38%). Smaller shares in this group say what they’ve heard or read in the news (19%) or on social media (18%) or their religious views (9%) have had a great deal or a fair amount of influence.

Among those who say gender is determined by sex assigned at birth, adults younger than 30 stand out as being more likely than their older counterparts to say their knowledge of science (60%), what they’ve heard or read on social media (22%) or knowing someone who is trans (17%) influenced this view a great deal or a fair amount. In turn, those ages 65 and older tend to be more likely than younger age groups to cite their religious views (51% in the older group say this has had at least a fair amount of influence). 

Republicans who say gender is determined by sex assigned at birth are more likely than Democrats with the same view to say their knowledge of science (52% vs. 40%) and their religious views (45% vs. 34%) have had at least a fair amount of influence, while Democrats are more likely than Republicans to say the news (17% vs. 10%), social media (16% vs. 10%) and knowing someone who is trans (15% vs. 9%) have influenced them – though the shares are still small among both groups.

U.S. adults with different viewpoints on gender and sex say their opinions have been influenced by different factors

On the flip side, among those who say someone’s gender can be  different  from the sex they were assigned at birth, adults younger than 30 are also more likely than older adults to say social media has contributed to this view at least a fair amount (33% vs. 15% or fewer among older age groups). Adults ages 65 and older are more likely than their younger counterparts to say what they’ve learned from science has influenced their view (46% vs. 40% or fewer). 

Democrats who say whether someone is a man or a woman can be different from their sex at birth are more likely than Republicans with the same view to say that what they’ve learned from science (43% vs. 26%) and knowing someone who is transgender (40% vs. 26%) has influenced their view a great deal or a fair amount.

Public sees discrimination against trans people and limited acceptance

Roughly eight-in-ten Americans say transgender people face at least some discrimination, and relatively few believe our society is extremely or very accepting of people who are trans. These views differ widely by partisanship and by beliefs about whether someone’s gender can differ from the sex they were assigned at birth.

Overall, 57% of adults say there is a great deal or a fair amount of discrimination against transgender people in our society today. An additional 21% say there is some discrimination against trans people, and 14% say there is a little or none at all. 

There are modest differences in views on this issue across demographic groups. Women (62%) are more likely than men (52%) to say there is a great deal or a fair amount of discrimination against transgender people, and college graduates (62%) are more likely than those with less education (55%) to say the same. 

Chart showing Most Americans say there is at least some discrimination against trans people in the U.S.

There is, however, a wide partisan divide in these views: While 76% of Democrats and those who lean to the Democratic Party say there is a great deal or a fair amount of discrimination against trans people, 35% of Republicans and Republican leaners share that assessment. One-in-four Republicans see little or no discrimination against this group, compared with 5% of Democrats. 

These views are also linked with underlying opinions about whether a person’s gender can be different from their sex assigned at birth. Among those who say someone can be a man or a woman even if that’s different from the sex they were assigned at birth, 83% say there is a great deal or a fair amount of discrimination against trans people. Even so, some 42% of those who hold the alternative point of view – that gender is determined by sex assigned at birth – also see at least a fair amount of discrimination. Among Democrats who say gender is determined by sex at birth, that share rises to 61%. 

Relatively few adults (14%) say society is extremely or very accepting, while about a third (35%) say it is somewhat accepting. A plurality (44%) says our society is a little or not at all accepting of trans people. 

Chart showing Plurality of Americans say there is little or no societal acceptance of transgender people

Again, these views are strongly linked with partisanship. Democrats have a much more negative view than Republicans, with 54% of Democrats saying society is a little accepting or not at all accepting of transgender people, compared with a third of Republicans. 

And, as with views of discrimination, assessments of societal acceptance are linked to underlying views about how gender is determined. Those who say one’s gender can be different from the sex they were assigned at birth see less acceptance: 56% say society is a little accepting or not accepting at all of people who are transgender. This compares with 37% among those who say gender is determined by sex at birth. Republicans who say gender is determined by sex at birth are more likely than Democrats who say the same to believe that society is at least somewhat accepting of people who are transgender (61% vs. 47%).

About four-in-ten say society has gone too far in accepting trans people

While a majority of Americans see at least a fair amount of discrimination against transgender people and relatively few see widespread acceptance, 38% say our society has gone too far in accepting them. Some 36% say society has not gone far enough in accepting people who are trans, and 23% say the level of acceptance has been about right.

These views differ along demographic and partisan lines. Young adults (ages 18 to 29) and those with a bachelor’s degree or more education are among the most likely to say society hasn’t gone far enough in accepting people who are trans. Men, White adults and those without a four-year college degree are among the most likely to say society has gone too far in this regard. 

Chart showing Public is divided over whether society has gone too far or not far enough in accepting transgender people

There is a wide partisan divide as well. Roughly six-in-ten Democrats (59%) say society hasn’t gone far enough in accepting people who are transgender, while 15% say it has gone too far (24% say it’s been about right). Republicans’ views are almost the inverse: 10% say society hasn’t gone far enough and 66% say it’s gone too far (22% say it’s been about right). 

Even among those who see at least some discrimination against trans people, a majority (54%) say society has either gone too far in accepting trans people or been about right; 44% say society hasn’t gone far enough.

Many say it’s important to use someone’s new name, pronouns when they’ve gone through a gender transition

Nearly half of adults say it’s important to use someone’s new name if they change their name  as part of a gender transition

Nearly half of adults (47%) say it’s extremely or very important that if a person who transitions to a gender that’s different from their sex assigned at birth changes their name, others refer to them by their new name. An additional 22% say this is somewhat important. Three-in-ten say this is a little or not at all important (18%) or that it shouldn’t be done (12%).

Smaller shares say that if a person transitions to a gender that’s different from their sex assigned at birth and starts going by different pronouns (such as “she” instead of “he”), it’s important that others refer to them by their new pronouns. About a third (34%) say this is extremely or very important, and 21% say this is somewhat important. More than four-in-ten say this is a little or not at all important (26%) or it should not be done (18%).

These views differ along many of the same dimensions as other topics asked about. While 80% of those who believe someone’s gender can be different from their sex assigned at birth also say it’s extremely or very important to use a person’s new name when they’ve gone through a gender transition, 27% of those who think gender is determined by one’s sex assigned at birth share this opinion. The pattern is similar when it comes to use of preferred pronouns. 

Democrats are much more likely than Republicans to say it’s extremely or very important to refer to a person using their new name or pronouns. When it comes to pronouns, a majority of Republicans (55%), compared with only 17% of Democrats, say using someone’s new pronouns when they’ve been through a gender transition is not at all important or should not be done.  

Chart showing People who know a trans person place more importance on using a person’s new name, pronouns if they transition

There are some demographic differences as well, with women more likely than men and those with a four-year college degree more likely than those with less education to say it’s extremely or very important to use a person’s new name or pronouns when referring to them.

In addition, people who say they know someone who is trans are more likely than those who do not to say this is extremely or very important. Even so, substantial shares of those who don’t know a trans person view this as important. For example, 39% of those who don’t know someone who is transgender say it’s extremely or very important to refer to a person who goes through a gender transition and changes their name by their new name. 

Plurality of adults say views on gender identity issues are changing too quickly

Many Americans are not comfortable with the pace of change that’s occurring around issues involving gender identity. Some 43% say views on issues related to people who are transgender and nonbinary are changing too quickly. About one-in-four (26%) say things are not changing quickly enough, and 28% say they are changing at about the right speed.

Women (30%) are more likely than men (21%) to say views on these issues are not changing quickly enough, and adults younger than 30 are more likely than their older counterparts to say the same. Among those ages 18 to 29, 37% say views on these issues are not changing quickly enough; this compares with 26% of those ages 30 to 49, 22% of those ages 50 to 64 and 19% of those 65 and older. At the same time, White adults (46%) are more likely than Black (34%), Hispanic (39%) or Asian (31%) adults to say views are changing  too quickly .

Chart showing More than four-in-ten Americans say societal views on gender identity are changing too quickly

Opinions also differ sharply by partisanship. Among Democrats, a plurality (42%) say views on issues involving transgender and nonbinary people are not changing fast enough, and 21% say they are changing too quickly. About a third (35%) say the speed is about right. By contrast, 70% of Republicans say views on these issues are changing too quickly, while only 7% say views aren’t changing fast enough. About one-in-five Republicans (21%) say they’re changing at about the right speed. 

Respondents were asked in an open-ended format why they think views are changing too quickly or not quickly enough, when it comes to issues surrounding transgender and nonbinary people. For those who say things are changing too quickly, responses fell into several different categories. Some indicated that new ways of thinking about gender were inconsistent with their religious beliefs. Others expressed concern that the long-term consequences of medical gender transitions are not well-known, or that changing views on gender identity are merely a fad that’s being pushed by the media. Still others said they worry that there’s too much discussion of these issues in schools these days.

In their own words: Why do some people think views on issues related to transgender people and those who don’t identify as a man or a woman are changing  too quickly ?

General concerns about the pace of change

“The issue is so new to me I can’t keep up. I don’t know what to think about all of this new information. I’m baffled by so many changes.”

“It takes quite a bit of time for society to accept changes. I have not been aware of this issue for very long. I am relatively conservative and feel that changes need time to be accepted.”

Religious reasons

“People now believe everyone should just forget about their birth identity and just go along with what they think they are. God made us all for a reason and if He intended us to pick our gender then there would be no reason to be born with specific male or female parts .”

“I have a personal religious belief that sex is an essential part of our eternal identity and that identifying as something other than you are … just doesn’t make a lot of sense.”

“I believe GOD created a man and a woman. We have overstepped our bounds in messing with the miracle of life. I side with my creator.”

Concerns about long-term medical consequences

“We do not know the long-term health problems of hormone therapy, especially in young children.”

“More time needs to pass to study mental, physical, emotional ramifications of medications & surgeries, especially when done before puberty and/or adulthood.”

“Accepting gender fluidity, especially for younger children, seems quick. Also, medical treatments related to gender for people under 18 seems to be being accepted without longer term studies.”

It’s a fad/Driven by the media

“I respect people’s views about themselves, and I will refer to them in the way they want to be referred to, but I believe it’s become trendy because it’s being pushed so much in culture, especially for children.”

“News media, social media and entertainment media companies are trying to change, and it seems they have been succeeding in changing public opinion on this issue for many people.”

“It is encouraging kids who are easily influenced to participate in the ‘in’ fad when their brains are not fully developed.”

Concerns about schools

“Elementary school students should not be subjected to instruction on sex identity, any questions the child asks should be referred to a parent.”

“I think that young people are exposed to these issues at too early an age. I believe that it is up to the parents, and I oppose schools that want to include it in the ‘curriculum.’”

“It’s being pushed on society and especially on younger children, confusing them all the more. This is not something that should be taught in schools.”

In their own words: Why do some people think views on issues related to transgender people and those who don’t identify as a man or a woman are changing  too slowly ?

Discrimination

“There is far too much discrimination, hate, and violence directed toward people who are brave enough to stand up for who they truly are. We, as a country and as a society, need to respect how people want to identify themselves and be kind toward one another, end of story.”

“Protections for basic rights to self-determination in identity, health care choices, privacy, and consensual relationships should be a bare minimum that our society can provide for everyone – transgender people included . ”

“There’s too much discrimination. People need to quit controlling other people’s private lives. I consider them very brave for having the courage to be who they identify with . ”

“Equal protection has not kept up with trans issues, including trans youth and the right to gender-affirming care.”

Legislative efforts

“Acceptance is not changing quick enough. There remains discrimination and elected officials are passing laws that make it more difficult for transgender individuals in society to live, work and exist.”

“We are going backwards with all the anti-gay & -trans legislation that is being passed.”

“For every step forward, it feels like there are two steps back with reactive conservative laws.”

“These laws are working to restrict the rights of trans and nonbinary people, and also discrimination is still very high which results in elevated rates of suicide, poverty, violence and homelessness especially for people of color.”

“The spate of laws being proposed that would take away the rights of transgender people is evidence that we’re a long way from treating them right.”

Society is not open to change

“Too many people are simply stuck in the binary. We, as a society, need to just accept that someone else’s gender identity is whatever they say it is and it rarely has any bearing on the lives of others.”

“These are people. Who they say they are is all that matters. Society, mostly conservatives, doesn’t understand change in any form. So, they fight it. And they hinder the ability for others to learn about themselves and others, which slows growing as a society to a crawl.” 

“It’s an issue that has been in the closet for centuries. It’s time to acknowledge and accept that gender identity is a spectrum and not binary.” 

“We are not accepting the changes. We refuse to see what is in front of us. We care too much about not changing the status quo as we know it.” 

“Society often views this as a phase or a period of uncertainty in their life. Instead, it’s about a person bringing their gender identity in line with what they have experienced internally all their life.”

Most say they’re not paying close attention to news about bills related to transgender people 

Chart showing Liberal Democrats are more likely than other groups to be following news about bills related to trans people closely

Only about one-in-ten or less across age, racial and ethnic groups, and across levels of educational attainment, say they are following news about bills related to people who are transgender extremely or very closely. Six-in-ten or more across demographic groups say they’re following news about these bills a little closely or not closely at all. 

Liberal Democrats and Democratic-leaning independents (46%) are more likely than moderate and conservative Democrats (29%) to say they are following news about state bills related to people who are transgender at least somewhat closely. Conservative Republicans and Republican leaners (31%) are more likely than their moderate and liberal counterparts (24%) – but less likely than liberal Democrats – to be following news about these bills at least somewhat closely. Still, half or more among each of these groups say they have been following news about this a little or not at all closely. 

About six-in-ten would favor requiring that transgender athletes compete on teams that match their sex at birth

The survey asked respondents how they feel about some current laws and policies that are either in place or being considered across the U.S. related to transgender issues. Only two of seven items are either endorsed or rejected by a majority: 64% say they would favor policies that protect transgender individuals from discrimination in jobs, housing, and public spaces such as restaurants and stores, and 58% say they would favor policies that require that transgender athletes compete on teams that match the sex they were assigned at birth rather than the gender they identify with. 

Chart showing Most Americans say they would favor laws that would protect transgender people from discrimination in jobs, housing and public spaces

Even though there is not a majority consensus on most of these laws or policies, there are gaps of at least 10 percentage points on three items. Some 46% say they would favor making it illegal for health care professionals to provide someone younger than 18 with medical care for gender transitions, and 41% would favor requiring transgender individuals to use public bathrooms that match the sex they were assigned at birth rather than the gender they identify with; 31% say they would oppose each of these. Meanwhile, more say they would  oppose  (44%) than say they would favor (27%) requiring health insurance companies to cover medical care for gender transitions. 

Views are more divided when it comes to laws and policies that would make it illegal for public school districts to teach about gender identity in elementary schools (41% favor and 38% oppose) or that would investigate parents for child abuse if they helped someone younger than 18 get medical care for a gender transition (37% favor and 36% oppose). Some 21% and 27%, respectively, say they’d neither favor nor oppose these policies. 

Views on many policies related to transgender issues vary by age, party, and race and ethnicity 

Majorities of U.S. adults across age groups express support for laws and policies that would protect transgender individuals from discrimination in jobs, housing, and public spaces such as restaurants and stores. About seven-in-ten adults ages 18 to 29 (70%) and 30 to 49 (68%) say they favor such protections, as do about six-in-ten adults ages 50 to 64 (60%) and 65 and older (59%). 

But adults younger than 30 are more likely than those in each of the older age groups to say they favor laws or policies that would require health insurance companies to cover medical care for gender transitions (37% among those younger than 30 vs. about a quarter among each of the older age groups). They’re also less likely than older adults to express support for bills and policies that would restrict the rights of people who are transgender or limit what schools teach about gender identity. On most items, those ages 50 to 64 and those 65 and older express similar views. 

Chart showing Views of laws and policies related to transgender issues differ by age

Views differ even more widely along party lines. For example, eight-in-ten Democrats say they favor laws or policies that would protect trans individuals from discrimination, compared with 48% of Republicans. Conversely, by margins of about 40 percentage points or more, Republicans are more likely than Democrats to express support for laws or policies that would do each of the following: require trans athletes to compete on teams that match the sex they were assigned at birth (85% of Republicans vs. 37% of Democrats favor); make it illegal for health care professionals to provide someone younger than 18 with medical care for a gender transition (72% vs. 26%); make it illegal for public school districts to teach about gender identity in elementary schools (69% vs. 18%); require transgender individuals to use public bathrooms that match the sex they were assigned at birth (67% vs. 20%); and investigate parents for child abuse if they help someone younger than 18 get medical care for a gender transition (59% vs. 17%). 

Overall, White adults tend to be more likely than Black, Hispanic and Asian adults to express support for laws and policies that would restrict the rights of transgender people or limit what schools can teach about gender identity. But among Democrats, White adults are often  less  likely than other groups to favor such laws and policies, particularly compared with their Black and Hispanic counterparts. And White Democrats are more likely than Black, Hispanic and Asian Democrats to say they favor protecting trans individuals from discrimination and requiring health insurance companies to cover medical care for gender transitions. 

Sizable shares say forms and government documents should include options other than ‘male’ and ‘female’

Chart showing About four-in-ten or more say forms and government documents should offer options other than ‘male’ and ‘female’

About four-in-ten Americans (38%) say government documents such as passports and driver’s licenses that ask about a person’s gender should include options other than “male” and “female” for people who don’t identify as either; a larger share (44%) say the same about forms and online profiles that ask about a person’s gender.

Half of adults younger than 30 say government documents that ask about gender should include options other than “male” and “female,” compared with 39% of those ages 30 to 49, 35% of those 50 to 64 and 33% of adults 65 and older. When it comes to forms and online profiles, 54% of adults younger than 30 and 47% of those ages 30 to 49 say these forms should include more than two gender options; smaller shares of adults ages 50 to 64 and 65 and older (37% each) say the same. 

Views on this vary considerably by party. A majority of Democrats and Democratic-leaning independents say forms and online profiles (64%) and government documents (58%) that ask about a person’s gender should include options other than “male” and “female.” In contrast, about eight-in-ten or more Republicans and Republican leaners say forms and online profiles (79%) and government documents (83%) should  not  include more than these two gender options. 

Those who say they know someone who is nonbinary are more likely than those who don’t know anyone who’s nonbinary to say forms and government documents should include gender options other than “male” and “female.” Still, 39% of those who don’t know anyone who’s nonbinary say forms and online profiles shouldinclude other gender options, and 33% say the same about government documents that ask about a person’s gender. Conversely, 31% of those who say they know someone who’s nonbinary say forms and online profiles should  not  include options other than “male” and “female,” and 41% say this about government documents. 

About three-in-ten parents of K-12 students say their children have learned about people who are trans or nonbinary at school 

In recent months, lawmakers in several states have introduced legislation that would  prohibit or limit instruction on sexual orientation or gender identity  in schools. The survey asked parents of K-12 students whether any of their children have learned about people who are transgender or who don’t identify as a boy or a girl from a teacher or another adult at their school and how they feel about the fact that their children have or have not learned about this.

Some 37% of parents with children in middle or high school say their middle or high schoolers have learned about people who are transgender or who don’t identify as a boy or a girl from a teacher or another adult at their school; a much smaller share of parents of elementary school students (16%) say the same. Overall, 29% of parents with children in elementary, middle or high school say at least one of their K-12 children have learned about this at school. 

Similar shares of parents of K-12 students in urban (31%), suburban (27%) and rural (32%) areas – and in the Northeast (34%), Midwest (33%), South (26%) and West (28%) – say their school-age children have learned about people who are transgender or who don’t identify as a boy or a girl. And Republican (27%) and Democratic (31%) parents are also about equally likely to say their children have learned about this in school. None of these differences are statistically significant.

Chart showing Views on children learning about people who are trans or nonbinary at school differ by party, children’s age

Many parents of K-12 students don’t think it’s good for their children to learn about people who are transgender or nonbinary from their teachers or other adults at school. Among parents of elementary school students, 45% either say their children have learned about people who are trans or nonbinary at school and see this is a  bad  thing or say their children have  not  learned about this and say this is a  good  thing. A far smaller share (13%) say it’s a good thing that their elementary school children have learned about people who are trans or nonbinary or that it’s a bad thing that they  haven’t  learned about this. And about four-in-ten (41%) say it’s neither good nor bad that their elementary school children have or haven’t learned about people who are transgender or nonbinary. 

Among parents with children in middle or high school, 34% say it’s a bad thing that their children have learned about people who are trans or nonbinary at school  or  that it’s a good thing that they haven’t; 14% say it’s good that their middle or high schoolers have learned about this  or  that it’s bad that they haven’t; and 51% say it’s neither good nor bad that their children have or haven’t learned about this in school. 

Republican and Republican-leaning parents with children in elementary, middle and high school are more likely than their Democratic and Democratic-leaning counterparts to say it’s a bad thing that their children have learned about people who are trans or nonbinary at school or that it’s a good thing that they haven’t. In turn, Democratic parents are more likely to say it’s  good  that their children  have  learned about this or  bad  that they  haven’t . They are also more likely to say it’s neither good nor bad that their children have or haven’t learned about people who are trans or nonbinary at school. 

  • For each policy item, respondents were also given the option of answering “neither favor nor oppose.”  ↩
  • Open-ended responses (quotations) have been lightly edited for clarity and length. ↩
  • The shares who say they are following news about this a little or not at all closely do not add up to the combined share shown in the chart due to rounding.  ↩

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Table of contents, q&a: how and why we surveyed americans about their views on gender identity, about 5% of young adults in the u.s. say their gender is different from their sex assigned at birth, the experiences, challenges and hopes of transgender and nonbinary u.s. adults, what is the gender wage gap in your metropolitan area find out with our pay gap calculator, deep partisan divide on whether greater acceptance of transgender people is good for society, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

Teachers, parents say kids should learn about racism. Sexuality much more divisive.

gender reassignment ethical issues

Activists have engaged in fierce debates in recent years over what kids should learn about race, sexual orientation and gender identity.

A new report from the Pew Research Center shows that while the majority of teachers, students and parents believe it's important to discuss racism in school, their opinions on other "culture war" subjects are mixed. Namely, there's a great divide over whether LGBTQ-related discussions have a place in the classroom. 

Half of teachers, for example, say students should not learn about gender identity in school, including nearly 2 in 3 elementary educators. Teens are also split about whether such discussions should take place in the classroom: About a third say the topic makes them uncomfortable. 

While "culture war" topics are "lumped together" in national conversations, teachers, students and other Americans tend to see these issues as separate, said Juliana Horowitz, associate director of research at Pew. 

Most teachers and members of the general public said parents should not be able to opt their kids out of race-related lessons even if that instruction conflicts with a family's viewpoint, Horowitz noted. But on lessons about sexual orientation or gender identity, roughly half of teachers and most Americans as a whole said parents should have opt-out rights.

As policymakers from both parties push for and pass legislation that dictates whether or how schools can teach about controversial topics, these findings indicate that public opinion on certain threads of that instruction remains very mixed. It also highlights that broad laws that restrict an array of topics can undermine learning. 

One relatively common belief among participants, including those who are right- and left-leaning, was that the government has too much influence over curriculum and that the "culture wars" are harming teachers’ ability to do their jobs. Most teachers say that regardless of what the pundits may say, LGBTQ-related discussions seldom, if ever, come up in the classroom. 

The surveys were conducted last fall among roughly 9,000 people, including about 5,000 members of the general public, 2,500 public school teachers and 1,500 teens.

Do ' culture war ' conversations cause discomfort?

A minority of the teens surveyed in the Pew sample said they are comfortable discussing these controversial themes in school. Just 38% expressed comfort with instruction about racism or racial inequality, and an even smaller portion – 29% – said they're fine with discussions related to sexual orientation and gender identity. 

Teachers were mixed about whether conversations about LGBTQ+ people have a place in the classroom. About half said kids shouldn’t learn about gender identity in school; the other half said they should. 

Among people who supported instruction about gender identity, teachers were twice as likely to say that instruction should acknowledge gender fluidity rather than emphasizing that a person's gender is determined by the sex assigned at birth. About a third of teachers said educators should teach that a person's gender “can be different from the sex they were assigned at birth.” Another 14% of teachers said they should teach that gender is fixed. 

Parents are almost evenly split on this topic of instruction, according to past Pew research. In a 2022 Pew survey , 37% said students should not learn about gender identity in school. There were also 31% who said children should learn that gender can be different from sex at birth. And another 31% said children should learn that gender is determined by sex at birth.

Tiffany Justice, co-founder of the parental rights group Moms for Liberty, said she was concerned that the “hyperfocus” on sexualizing instruction across grade levels was happening at the expense of math and literacy education. “Kids do not need a sexual spirit guide in the classroom,” she said. “They don’t need to know the sexual orientation of their teacher.”

Justice believes that teaching about racism in an accurate and age-appropriate way is far more pertinent than teaching about sexuality.

Ginny Gentles, director of the Independent Women's Forum’s Education Freedom Center, shared that perspective. She highlighted nuances within LGBTQ-related instruction. It’s one thing to teach about same-sex relationships, she said, and another to explain that gender identity isn’t necessarily “aligned with biological reality.”

Kids “are inundated with alternative identities … bombarded with that culture,” she said. “It could be that they’ve had enough.”

One notable finding in the Pew study is how divided teens are – even more than teachers – in their stances on LGBTQ-related education. Close to half said they shouldn’t learn about gender identity in school. A quarter said they would rather learn that gender and sex at birth can be different, and 26% said they would rather learn that sex at birth determines gender. 

“Teens are a lot more comfortable when topics related to racism or racial inequality come up” than when gender identity is discussed, Pew’s Horowitz said. “It may not even necessarily be a discomfort with the topic but perhaps it's a discomfort with the topic in the context of the classroom.” 

LGBTQ+ advocates: Legislative trends hurt young people's mental health 

Casey Pick, director of law and policy at the Trevor Project, which focuses on suicide prevention for LGBTQ+ young people, said research shows the lack of inclusive classrooms in certain communities correlates with higher rates of youth suicide. Inclusion can mean offering lesson plans about the historic contributions of LGBTQ+ people or training that shows teachers how to be allies to queer youth and better respond to bullying.

Pick said she isn’t surprised “that public opinion is divided and that many people feel confused or conflicted on the topic.”

“In recent years we’ve seen a resurgence of legislation that would silence this kind of discussion," she said. "What this (trend) does is it capitalizes on the well-intentioned desire of parents to protect their children.” 

Rae Sweet, a senior education coordinator with the It Gets Better Project, aimed at supporting LGBTQ+ young people, worries the legislative trend toward restricting teachers and the hatred it fuels may help explain the death earlier this month of a gender-expansive student in Oklahoma.

Nex Benedict died after being injured in a fight at school. Benedict's school district had been targeted by Chaya Raichik, a prominent conservative behind the social media account Libs of TikTok, who was recently appointed to a state library advisory committee.

“What would’ve happened if these schools were teaching acceptance?” Sweet said. Sweet said they’ve observed educators going “underground” in their allyship amid growing pressures to remove these lessons from their teaching. 

Jeremy T., a high school student in the Houston area, said he has witnessed resources and supportive imagery being removed from his campus as the "culture wars" have exploded in his state. Pride flags have been banned, and the school library's shelves are largely empty as books go under review en masse over concerns about their coverage of topics such as LGBTQ+ issues.

Jeremy, who asked that his last name be concealed over fear of backlash at school, said his peers regularly make jokes and bullying remarks about queer people. He's surprised that the percentage of teens who said they'd rather not learn about gender identity in class isn't higher.

"It's a misconception from both the right and left, overestimating how progressive young people are," the senior said. "We aren't going backwards – we are (already) in the negative."

Divided opinions harm learning, separate report shows

A separate new report out of the University of Southern California, the largest and most detailed survey of its kind, found that partisan divides continue to determine perspectives on curriculum issues. Those divides were especially predictive of opinions on sexuality and gender identity, the study found.

Still, there are nuances. Fewer Democrats supported transgender inclusion in the curriculum compared with support for inclusion of other "culture war" topics and LGBTQ+ issues. For example, fewer than 2 in 3 supported using a student's chosen pronouns without asking the person's parents or discussing whether students ought to play on sports teams that match their gender identity. 

“The trans issues and gender identity issues are by far the most fraught,” said Morgan Polikoff, an associate professor of education who co-wrote the University of Southern California report. “There is a very real and important discussion to be had about what is age-appropriate with regard to these topics. … It’s not that we should definitely do all of these things or shouldn’t do any of them.”

The intense partisan disagreement on LGBTQ+ issues may help explain why so many teachers want such discussions to stay out of their classrooms.

Of the teachers in the Pew survey, 41% said these debates had a harmful effect on their jobs. Just a sliver said the impact was positive. The remainder of the educators were neutral. 

“Teachers are feeling like this conversation and these decisions are being made without them and without their guidance and without their involvement,” said Horowitz, from the Pew study. “We do see party divides, but when it comes to how much influence teachers have, similar shares of Democratic and Republican teachers say teachers don't have enough influence."

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